•nia 
1 


TREATISE 

.^- 

" 


DISEASES  OF  FEMALES, 


EY 


WILLIAM  P.  DEWEES,  M.D., 

=£-  :=: 

IATE   PROFKS80E  Ot  MIDWIFERY  IN  THE  UNIVERSITY  O¥  PENNSYLVANIA 
OF  THE  AMERICAN  PHILOSOPHICAL  SOCIETY;    OF  THE  ROYAL 
MEDICAL  SOCIETY  OF  DENMARK,  &C.,  &C. 


•     * 

WITH   ILLUSTRATIONS. 


/HE  AUTHOR'S  LAST  IMFROyELlENTS  AND  "CORRECTIONS 


UBANCHARD   AND    LEA. 
1853. 


K 


Eastern  District  of  Pennsylvania,  to  wit : — 

BE  IT  REMEMBERED,  that,  on  the  twentieth  day  of  November,  in  the  fifty- 
lirst  year  of  the  Independence  of  the  United  States  of  America,  A.  D.  1827, 
WILLIAM  P.  DEWEES,  M.  D.,  of  the  said  district,  hath  deposited  in  this  office  the 
title  of  a  book,  the  right  whereof  he  claims  as  Author,  in  the  words  following,  to 
•A-it:— 

"  A  Treatise  on  the  Diseases  of  Females.     By  William  P.  Dewees,  M.  D.     Pro- 
fessor of  Midwifery  in  the  University  of  Pennsylvania,  &c.  &c." 

In  conformity  to  the  Act  of  the  Congress  of  the  United  States,  entitled,  "  An 
Act  for  the  Encouragement  of  Learning,  by  securing  the  Copies  of  Maps,  Charts, 
and  Books,  to  the  Authors  and  Proprietors  of  such  Copies,  during  the  times  therein 
mentioned — And  also  to  the  Act,  entitled,  "An  Act  supplementary  to  an  Act, 
entitled,  'An  Act  for  the  Encouragement  of  Learning,  by  securing  the  Copies  of 
Maps,  Charts,  and  Books,  to  the  Authors  and  Proprietors  of  such  Copies,  during 
the  times  therein  mentioned,'  and  extending  the  benefits  thereof  to  the  arts  of 
,  engraving,  and  etching  Historical  and  other  Prints.'' 

D.  CALDWELL, 
Clerk  of  the  Eastern  District  of  Pennsylvania. 


VT3J.   8.   YOUNG,   PRIXTEE. 


TO 
K.    CHAPMAN,  M.D., 

1'ROFJCSSOR  OF  INSTITUTES  AND  PRACTICE  OF  PHYSIC,  ETC.,  ETC.. 


Ciji5  iTjork  is 


WITH  SENTIMENTS  OF  THE  HIGHESt  ESTEEM,  TOR  HIS  MANY  VIRTUE; 
AND  THE  SINCEREST  ADMIRATION  OF  HIS  VARIOUS  TALENTS, 

BY  HIS  OBLIGED  FRIEND, 

THE   AUTHOR. 


*>    •    V :  A  U  T  H  0  R '  S    <  f-?, . 
ADVERTI  S.BMENT. 


THE  following  pages  are  presented  to  the  public  with- 
'  out  preface  or  apology.  The  necessity  of  a  work  on  the 
Diseases  of  Females,  and  especially  the  most  common  of 
them,  seems  to  be  pretty  generally  acknowledged;  but 
the  difficulty  of  executing  it  can  only  be  known  to  him 
who  undertakes  it.  This  will  plead  with  the  liberal  for 
moderation  in  criticism;  though  it  may  be  no  extenu- 
ation Avith  those  of  a  contrary  feeling.  From  the  ob- 
servations of  the  former  we  hope  to  profit,  should  any 
Hiich  honour  the  work  with  their  notice;  and  from  the 
latter  we  will  not  flinch,  however  severe  the  castigation, 
as  we  know  it  is  much  easier  to  find  fault  than  to  excel. 


THE  present  edition  of  this  valuable  work  contains  the 
revisions  and  additions  of  the  author,  made  by  him  a 
short  time  previous  to  his  death. 


CONTENTS. 


CHAPTER  I. 

Page. 

Of  the  Peculiarities  of  the  Female  System,         .  .         17 

CHAPTER  II. 

Of  the  Diseases  of  the  External  and  Internal  Organs,  25 

SECT.  I.  Of  the  Tumours  and  Excrescences  of  the  Exter- 
nal parts,     .  .          T. •.•'.!         «•«•          •         26 
II.  Of  the  Diseases  of  the  Nymphse,     •.  .  26 
III.  Of  the  Diseases  of  the  Clitoris,              .             .         28 
IV.  Of  the  Adhesion  of  the  Labia  Pudendi  of  Chil- 
dren,      .                                       . 

V.  Of  the  Abscesses  of  the  Labia,  .  .         32 

VI.  (Edematous  Swelling  of  the  Labia,  '  ^  33 

VII.  Of  Bloody  Infiltrations  in  the  Labia  during  or 

after  Delivery,          ....         35 
VIII.  Imperforation,  and  too  great  Density  of  the 

Hymen,  ....  42 

IX.  Of  Pruritus,  or  Aphthous  Condition  of  the  Vulva 

and  Vagina,        ....  46 

CHAPTER  III. 

Of  the  Diseases  of  the  Vagina,  .  .  .54 

CHAPTER  IV. 

Of  Leucorrhoea,  .  .  .  .  .55 

Method  of  Cure,       .  •  &  .  72 

CHAPTER  V. 

Of  the  History  of  Menstruation,  *  .  .  .         79 


Xii  CONTENTS. 

CHAPTER  VI. 

Page. 

Of  Deranged  Menstruation,      .             .                      ^..  101 

SECT.  I.  1.  Of  the  Tardy  Appearance  of  the  Menses,  101 

II.  2.  Of  the  Suppression  of  the  Menses,             .  110 

Case  I.           ...  115 

Case  II.                 ...  Ill) 

III.  3.  Of  the  Immoderate  Flow  of  the  Menses,  123 

IV.  4.  Of  Dysmenorrhoea,  or  Painful  Menstruation,  125 
V.  5.  Of  the  Decline  of  the  Menses,       .             .  138 

CHAPTER  VII. 

Of  Menorrhagia,            .             .             .             .             *  150 

CHAPTER  VIII. 

Of  the  Signs  which  usually  accompany  Pregnancy,       .  161 

SECT.  I.     1.  Suppression  of  the  Menses,     .             .  162 

II.     2.  Nausea  and  Vomiting,      .             .             .  167 

III.  3.  Enlargement  of  the  Mammae,               .  168 

IV.  4.  Areolte,                 .             .             ..         ;..'  168 
V.     5.  Formation  of  the  Milk,            .             .  16i> 

VI.     6.  Enlargement  of  the  Abdomen, f    .           +.  170 

VII.     7.  Increased  size  of  the  Uterus,               .  171 

VIII.     8.  Pouting  out  of  the  Navel,              .             .  172 

IX.     9.  Spitting  of  Frothy  Saliva,       .             .  172 

X.  10.  Salivation,  .  .  .  .173 

XL  11.  Of  Quickening,            ...  174 

'CHAPTER  ix. 

Of  the  General  Condition  of  the  System,  and  the  Effects 

of  certain  Remedies  during  Pregnancy,         .             .  180 

Bleeding,         ....  186 

Purging,                 .             .             .             .  188 

Emetics,           .  189 
Blisters,                 .            $           .             .190 

CHAPTER  X. 

On  some  of  the  Diseases  of  Pregnancy,             .             .  191 
SECT.  I.  Of  the  Febrile  Condition  of  the  System  during 

Pregnancy,              .             .            vj           .  191 


CONTENTS.  Xlii 

Page. 

SECT.  II.  Of  Vomiting,          **?V          .            .  .  *      195 

III.  Of  Heartburn,     .             .            &         •  199 

IV.  Of  Salivation,            .         .„.,,,'         .  .         200 
V.  Of  Pain  in  the  Right  Side,        '.,.*•       "-.>  202 

VI.  Of  Inquietude  and  Want  of  Sleep,    .  .         204 

VII.  Of  Costiveness,    .            .            .         r*  205 

CHAPTER  XI. 

Of  Hemorrhoids,  or  Piles,         ....  208 

CHAPTER  XII. 

Of  Palpitation  of  the  Heart,     .  216 

CHAPTER  XIII. 

Of  the  Displacement  of  the  Uterus, 
SECT.  I.  Prolapsus  of  the  Uterus, 

II.  Of  the  Chronic  Inversion  of  the 

CHAPTER  XIV. 

Of  the  Diseases  of  the  Uterus,  Ovaria  and  Tubes,  ,        236 

SECT.  I.  Of  the  Disorders-  and  Diseases  of  the  Uterus,  236 

II.  Of  the  Diseases  of  the  Ovaries,     .             ..  237 

III.  Of  the  Diseases  of  the  Tubes,             .  .         238 

CHAPTER  XV, 

Of  the  Particular  Diseases  of  the  Uterus,         ..  -        240 

SECT.  I.  Of  the  Carcinoma  Uteri,                .  242 

II.  Of  the  Treatment  of  Carcinoma  Uteri,  .         244 

1.  Abstracting  Blood,             .             .  245 

2.  Purging,          .             .            .  .247 

3.  Abstemious  Diet,               ',          ?  •'  2491 

4.  Cleanliness,     .             .            »'.''  250 

5.  Rest,         .  252: 

III.  Of  the  Polypus  of  the  Uterus,            ,  .        260 

Case  I.           .            .            .'           .  266 

Case  II.               ....  266 

Caselll 267 

Case  IV.             ....  268 

CaseV 269 

Case  VI.  270 


XIV  CONTENTS. 

«. 

Page. 

SECT.  IV.  Mode  of  applying  the  Ligature  for  Polypi,  271 

V.  Of  the  Cauliflower  Excrescence,  275 

VI.  Of  the  Symptoms,                 .         "V"      '  ; ''  278 

VII.  Of  the  Prognostics,         .             .          :  .  *  278 

VIII.  Of  the  Treatment  of  Cauliflower  Excrescence,  279 

IX.  Of  the  Hydatids  of  the  Uterus,  s  '>.'           .  283 

X.  Of  the  Irritable  Uterus,  290 

m"t    i    >"Prt ;  it- » 
•I  .- 

CHAPTER  XVI. 

Of  Uterine  Hemorrhage,  .  .  ,  ,311 

SECT.  I.  1.  Of  the  Connexion  of  the  Ovum  with  the 

Uterus,  .  .  .  .311 

II.  2.  Of  the  Causes  which  may  tend  to  destroy 

this  Connexion,             .             .             .  312 

III.  3.  Of  the  Mode  of  Action  of  certain  of  the 

remote  Causes,             ,             .             .  312 

IV.  4.  Of  the  Periods  of  Pregnancy  at  which  He- 

morrhage may  take  place,        -v  r          .  .1  316 

First  Period,                .             .            *  318 
Second  Period,      .             .             .             .326 
V.  Delivery  considered  as  a  Mode  of  arresting 

Hemorrhage,            '    J  *'          :  328 

CHAPTER  XVII. 

Hysteritis,  or  Inflammation  of  the  Uterus,       ..         \t  .  ',  333 

SECT.  I.  SPECIES  FIRST.     1.  Cause,           .         ^*.  334 

2.  Symptoms,             ....  335 

3.  Constitutional  Symptoms,         .             .  336 
II.  SPECIES  SECOND.     On  the  mixed  Inflammation 

of  the  Uterus,  or  Accidental  Puerperal  Fever,  340 

Treatment,     .           \           1. •'  '        ,r            .  342 

a.  Bleeding,       .  •,          .         '    .  v         .  342 

b.  Purging,             •  .             .  "          .             .  344 
a.  Fomentations,             .          '  ,             .  344 

d.  Blisters,               vr         .                         .  345 

e.  Sudorifics,      '.  345 
/.  Opium,    .             .            .,            .  346 
g.  Emetics,         .            .            .            .  346 

CHAPTER  XVIII. 

Of  Puerperal  Fever,     .             .             .         i>  .             .  347 

History,              .             .             .             .  350 

Predisposing  Causes,          '  ''?'•*•         .            .             .  352 


CONTENTS.  XV 

« 

<4  Page. 

Prophylactics,               .             .             .                      *  *••  355 

Seat  of  the  Disease,  and  its  proximate  Causes,    V-'v-1  357 

Period  of  Attack,  and  Symptoms,      ':'1'^-'      &'.          •   ;'  373 

Diagnosis,                .             .             .             .             .  379 

Prognosis,         .             .             .           ,j  *          »             .  381 

Contagious  Nature  of  Puerperal  Fever,  '   1%        >    *  384 

Treatment,        .....          ,;  ,JB  385 

1.  Bleeding,  Stage  First,          ,ft         fff)v;      ,.[j!';j  395 
Purging,                .             v-        -,„..       -/'- o,       i}*J  409 
Emetics,          .             .          -[v.       .,,jv/         ;,  409 
Blisters,                 .             .             BfJ'r       j  .;.;           .  412 
Fomentations,           •.-»,-)..,      -:!..c          ^          • 

Spirit  of  Turpentine,        .         r-:>'ni          •  • 

Mercurial  Frictions,              .  ^.",      \^--          .  414 

2.  Of  the  Gangrenous  Stage,          ,3^  r          .             .  416 

3.  Of  the  Stage  of  Effusion,     ,>/ '      .-.;,-           .  421 
General  Directions  and  Rules,            , .»   >      ,:<fr.        , ).  i  422 


CHAPTER  XIX. 

Phlegmasia  Dolens,  or  Milk  Leg,                 .          '' t  '-  p  424 

Symptoms  and  General  Character  of  Phlebitis,          >;.  •      438 

Case  I.     .             .             .           '7'         .^'  439 

Case  II.                       .             .             .             .  441 

Case  III.              ....  441 

Case  IV.        .  .  '   .  .442 

Method  of  Cure,      ...  446 

Blood-letting  and  Leeching,       .             .             .  447 

Purging,  &c.  447 

Topical  Applications,     ....  447 

Opium,         ...                         .  448 

External  Applications,               .             .             .  449 

Blisters,       .  449 

Bandaging,         .....  450 


CHAPTER  XX. 

Of  Milk  Abscess,          .....  451 

Of  the  Treatment,  ....  455 

1.  Local  Applications,  .  .  .  456 

2.  Regimen,  .  .  .  .  459 

3.  Purging,       .....  459 

4.  Puncturing,          ....  459 


XVI  CONTENTS, 


Page. 

5.  Caustic,         .  .  .  .          *  ;  -  •     460 

6.  Seton,     ......  460 

7.  After- Treatment,      .  .  .  .461 


CHAPTER  XXI. 

Of  Hysteria,              ,    .             .             •  •        ft*  .462 

SECT.  I.  Of  the  predisposing  Causes,           .             .  468 

II.  Of  the  exciting  Causes,           .             .  .         470 

1,  2.  Wind  and  Tough  Phlegm,             .  471 

3.  Worms,  475 

4.  Aliments,  improper   in    Quantity  or 

Quality,      .             .             .  .476 

5.  Schirrhous  or  other  Obstructions  in 

the  Stomach,  or  Intestines,  &c.  .         477 

6.  Violent  Affections  of  the  Mind,  478 

III.  Of  the  Phenomena  of  Hysteria,           .  .         479 

IV.  Diagnosis,              ....  482 
V.  Treatment,  .'*     483 

Case  I.                ....  487 

Case  II 488 

1.  Of  the  Paroxysm, 

2.  To  prevent  the  Recurrence  of  Paroxysms  ^        499 
Explanation  of  the  Plates,               .             .           •  \  ••*           511 
Index,               .             .             .             .             .  .523 


ON 


THE  DISEASES  OF  FEMALES. 


CHAPTER   I. 


OF   THE   PECULIARITIES   OF   THE    FEMALE  SYSTEM. 

HOWEVER  powerful  the  influence  of  education  and  modes  of  life 
may  be  upon  the  human  frame,  they  are  not  capable  of  effecting 
so  great  a  change  upon  the  female  constitution,  as  to  deprive  it  of 
its  distinctive  peculiarities.  Yet  we  are  aware  that  much  is  done 
by  these  great  agents ;  and  that  when  they  have  been  employed 
under  equal  circumstances,  for  an  equal  period,  an  approxima- 
tion of  physical  and  moral  similarity  has  been  observed ;  though 
they  have  never  been  able  to  alter  the  general  character  of  the 
female  BO  much,  as  to  leave  the  slightest  doubt  to  which  of  the 
sexes  the  individual  belongs,  even  independently  of  sexual  pecu- 
liarity. 

The  intentions  of  nature  in  the  formation  of  man,  are  not,  and 
cannot  be  fulfilled,  by  one  sex  alone;  both  must  concur  in  this 
great  objeefr;  and  it  would  be  idle  to  decide,  by  any  process  of 
reasoning,  to  which  is  assigned  the  most  important  role  in  this 
great  work.  Participation  is  essential  to  the  end  in  view;  and 
to  each  is  allotted  respective  duties ;  duties  which  cannot  be  ex- 
changed or  even  varied;  for  they  are  immutable.  To  preserve, 
therefore,  the  moral  and  physical  distinctions  in  his  favourite 
creatures,  and  to  prevent  either  neglect  or  confusion  in  the  per- 
formance of  the  duties  assigned  to  them,  the  Deity  has  imposed 
such  distinctness  of  organization  upon  the  sexes,  as  defies  aliena- 
tion, or  exchange  in  the  exercise  of  the  functions  resulting  from 
it.1 

1  Alphore  le  Roi  is  of  opinion,  that  most  of  the  causes  which  degenerate  the 
human  family,  originate  with  the  female.  He  says,  "  With  a  view  more  effectually 

2 


18  PECULIARITIES    OP 

In  this  place,  however,  we  have  only  to  detail,  and  that  very 
briefly,  the  peculiarities  which  distinguish  the  female  from  the 
male ;  peculiarities  which  impose  upon  her  functions  and  diseases 
altogether  her  own.  For  both  her  particular  organization  and 
her  temperament  are  made  subservient  to  the  important  part  she 
is  destined  to  perform;  upon  her  devolves  conception,  gestation, 
delivery,  suckling,  and  all  the  contingencies  connected  with  these 
processes. 

To  what  evils,  then,  do  not  these  processes  subject  the  female ! 
yet,  before  she  experiences  them,  she  is  liable  to  all  such  as  may 
arise  from  sexual  functions  and  organization:  and  before  she  can 
perform  one  of  the  ultimate  intentions  of  her  creation,  she  is  ob- 
noxious from  mere  structure  to  painful,  and  sometimes  to  fatal 
diseases. 

For  to  her  the  period  of  puberty  is  oftentimes  replete  with 
evils ;  she  is  constantly  liable  to  irregularities  in  her  menstrua, 
and  menaced  severely  by  their  consequences.  She  may  be  visited 
by  them  precociously,  and  be  debilitated  by  their  quantity  or 
frequency ;  or  they  may  be  withheld  so  long,  as  to  involve  her 
health  in  ruin.  Or  she  may  be  defective  or  exuberant  in  struc- 
ture ;  and  be  obliged  to  submit,  if  not  to  dangerous,  yet  perhaps 
to  indelicate  operations,  to  compensate  for  the  one  or  for  the 
removal  of  the  other.  Besides  these,  she  is  liable  to  all  the  dis- 
eases of  the  male,  that  do  not  depend  upon  sexual  distinction ; 
and  thus  is  multiplied  upon  her  almost  all  the  evils  that  can  befall 
two  sexes. 

The  anatomical  and  physiological  peculiarities  of  the  female  are 
both  numerous  and  curious;  we  shall  only,  however,  succinctly 
enumerate  a  few. 

One  of  the  most  striking  differences  between  the  male  and  fe- 
male, is  the  inferiority  of  her  stature.  Her  whole  osseous  fabric 
is  more  delicate  and  less  extended.  The  bones  of  her  cranium 
are  thinner,  smaller,  and  more  pliant;  and  the  space  destined  to 
be  filled  with  the  brain,  is  smaller. 

The  chest  is  more  elevated,  in  consequence  of  the  ribs  forming 
nearly  right  angles  with  the  spine ;  and  these  bones  themselves 
are  broader  and  flatter  than  in  the  male.  This  disposition  of  the 
ribs  renders  the  thorax  shorter,  though  its  upper  part  is  larger ; 
but  the  sternum  and  cartilages  have  less  length,  and  are  flatter ; 
the  clavicles  are  longer  and  less  crooked.  The  pelvis  of  the 
female  differs  in  a  number  of  points  from  that  of  the  male ;  it  is 

to  follow  the  labyrinth  of  the  human  economy,  it  appears  necessary  to  study  that 
of  the  female;  in  this  we  may  perceive  more  certainly  and  frequently  than  in  that 
of  the  man,  the  cause  and  progress  of  diseases.  Moreover,  the  degeneration  of 
the  species  always  begins  in  nature  with  the  female;  to  study  the  diseases  of  them 
is  to  arrive  at  the  source  of  all  that  belong  to  the  human  species."  Histoire  Na- 
turelle  de  la  Grossesse  et  1'Accouchement,  p.  viii. 


. 

THE    FEMALE    SYSTEM.  19 

calculated  to  subserve  one  of  the  most  important  as  well  as  inte- 
resting functions  of  the  body;  namely,  the  passage  of  the  child 
during  labour :  hence,  we  find  all  its  diameters  larger  than  those 
of  the  male ;  together  with  a  much  greater  expansion  of  the  bones 
which  constitute  the  arch  of  the  pubes,  &c. 

The  general  characters  of  the  bones,  as  well  as  their  connex- 
ions with  each  other,  differ  from  those  of  the  male ;  their  angles 
are  less  silent;  and  consequently  their  articulations  are  better 
concealed. 

The  muscular  system  also  differs ;  its  mobility  is  much  greater ; 
the  whole  of  the  fibres  of  the  female  seem  to  possess  a  greater 
tenuity  and  sensibility;  hence,  the  proneness  of  the  female  to 
spasmodic  and  convulsive  diseases;  hence,  the  greater  suscepti- 
bility of  impressions  from  physical  and  moral  causes:  hence,  the 
greater  quickness  of  contraction  of  the  muscles;  and  hence,  less 
permanency  of  impressions. 

The  nervous  system  has  also  its  peculiar  properties ;  the  nerves 
themselves  are  smaller,  and  of  more  delicate  structure.  They 
are  endowed  with  greater  sensibility,  and  of  course  are  liable  to 
more  frequent  and  stronger  impressions  from  external  agents,  or 
moral  influences ;  and  thus  the  nervous,  with  the  muscular  system, 
contribute  to  render  the  female  liable  to  spasmodic  diseases,  and 
obnoxious  to  inordinate  stimulation. 

But  these  peculiarities  are  considered  by  some,  rather  an  ad- 
vantage, than  an  evil.  Thus  Vigarous  declares,  "  Cette  sensi- 
bilite"  excessive,  loin  d'etre  un  mal,  devient  un  avantage  dans  leur 
condition ;  car  plus  les  sensations  sont  grandes,  moins  elles  sont 
durable,  parce  que  la  mollesse  et  la  flaccidite  des  solids  leur  faisant 
opposer  moins  de  r6sistance,  leur  r6action  est  moins  forte  et  cesse 
bientot." 

"  111  n'en  est  pas  de  meme  dans  1'homme  ;  la  rigidite  et  la  force 
de  ses  solides  exigent  plus  d'energie  et  un  plus  grand  degre 
d'entensite  dans  la  cause  qui  agit  sur  lui;  mais  aussi  reflect  est 
plus  durable,  par  la  grand  resistance  que  sont  en  6tat  d'opposer 
ses  organs,  resistance  qui  le  fait  souvent  succomber.  Je  compa- 
rerois  volentiers,  dans  ce  cas,  la  femme  £  ce  frele  roseau,  qui,  in- 
capable de  resistance,  flechit  humblement  la  tete  sous  1'effort  de 
la  tempete,  et  la  releve  doucement  quand  le  calme  est  revenue; 
et  1'homme  a.ce  chene  altier,  qui  se  trouve  abuttu,  par  la  seule 
raison  qu'il  est  fort  et  capable  de  resister."1 

In  the  sanguiferous  system,  we  may  perhaps  recognise  the 
united  peculiarities  of  the  muscular  and  nervous  systems ;  for  in 
that  system  we  constantly  find  the  circulation  carried  on  with 
more  rapidity,  but  with  less  force ;  the  arteries  are  smaller,  more 
irritable,  and  more  easily  urged  into  action,  and  less  easily  ap- 

HJ 

1  Maladies  des  Femmes.     Vol.  i.  p.  40. 


*    ••»• 

20  PECULIARITIES     OF 


peased,  after  having  been  inordinately  excited.  The  veins  offer 
less  resistance  to  any  given  distending  force;  hence,  they  are 
more  strongly  marked  upon  the  surface  of  the  body;  more  de- 
cidedly full,  or  permanently  distended ;  and  more  disposed  to  be- 
come varicose.  The  arteries  have  smaller  calibers ;  are  quicker 
in  their  action ;  and  but  rarely  ossify. 

The  cellular  -system  is  more  abundant ;  more  flexible ;  and 
more  easily  distended.  It  is  better  supplied  with  moisture ;  and 
from  the  compressibility  of  its  texture,  permits  the  blood  vessels 
to  divaricate,  and  pass  unrestrainedly  in  all  directions  through  it. 
From  its  abundance,  and  especially  about  the  articulations  of  the 
great  joints,  and  large  foldings  of  the  body,  a  roundness  and 
beauty  is  given  to  parts,  which  in  the  male  are  angular,  and  per- 
haps even  sometimes  unsightly. 

The  cutaneous  system  differs  much  from  that  of  the  male ;  for 
it,  of  itself,  almost  becomes  an  object  of  beauty.  Its  texture  is 
infinitely  finer,  more  highly  polished,  and  more  decidedly  trans- 
parent. It  permits  the  veins  to  ramify  gracefully  through  its 
structure;  to  be  distinctly  seen,  and  thus  forming  a  fine  contrast 
with  the  white  ground  on  which  they  repose.  It  shows,  from  its 
fineness,  to  the  greatest  possible  advantage,  the  arterial  termina- 
tions which  so  beautifully  assemble  upon  the  cheeks.  Its  sensi- 
bility is  much  greater ;  and  its  sympathies,  if  not  more  extensive, 
are  certainly  more  vivid,  than  in  the  male.  It  is  also  much  more 
distensible ;  especially  that  portion  of  it  which  covers  the  abdo- 
men ;  and  makes,  by  this  means,  an  important  provision  for  the 
period  of  gestation.  The  capillary  system,  also  appears  to  be 
more  developed  in  the  female  than  in  the  male  system.  Thus  the 
great  aptitude  of  the  system  of  the  former,  to  diseases  attended 
with  paleness  of  the  skin,  oedema,  dropsy,  and  hemorrhages,  and 
thus  involving  affections  of  both  the  serous  and  the  mucous 
surfaces. 

The  lymphatic  system  of  the  female  does  not  differ  widely,  as 
regards  conformation,  from  that  system  in  the  male:  it  absorbs 
and  transmits,  perhaps,  with  more  rapidity,  its  appropriate  fluids  ; 
yet,  there  is  no  other  known  peculiarity  in  it,  except  the  lympha- 
tic vessels  are  more  numerous  ;  and  when  they  have  a  certain  pre- 
dominance, they  constitute  a  temperament;  and  then,  unfortu- 
nately for  the  possessor,  it  but  too  certainly  and  too  frequently, 
becomes  the  seat  of  terrible,  and  oftentimes  incurable  disease. 

The  peculiarities  which  we  have  thus  briefly  pointed  out  ne- 
cessarily render  the  female  constitution  one  of  a  marked  and 
distinct  character.  The  assemblage  of  the  differences  which  con- 
stitute it,  renders  it,  in  general  terms,  one  in  which  the  solids  arc 
less  dense  and  resisting :  for  these  are  found  to  be  more  relaxed 
and  flabby  than  in  the  male,  owing,  probably,  to  the  predominance 
of  the  cellular  and  nervous  systems.  The  lymphatic  system  is 


THE    FEMALE    SYSTEM.  21 

more  extensive  than  the  sanguineous ;  which,  it  is  supposed,  gives 
to  the  female  a  greater  quantity  of  fluids  than  to  the  male. 

To  the  operation  of  several  of  the  peculiarities  above  enume- 
rated, is  attributed  the  supposed  predominant  temperament  of  the 
female  constitution ;  namely,  the  sanguineous  temperament,  so 
much  insisted  on  by  Rousel,  and  agreed  to  by  Vigarous. 

In  attributing  the  sanguineous  temperament  as  the  predomi- 
nant one  of  the  female,  we  only  mean  to  express  it  as  occurring 
as  a  general  rule;  for  we  are  aware  that  there  are  many  excep- 
tions to  be  found ;  for,  among  them,  as  with  the  male,  every  tem- 
perament may  be  seen.  It  has,  however,  been  given  so  general- 
ly, that  some  object  must  attach  to  its  frequency ;  and  perhaps 
the  opinion  of  Vigarous  is  as  plausible  as  any.  He  says,  "Des- 
tinees,  comme  elles  le  sont  (females)  at  passer  de  revolutions  en 
revolutions,  &  eprouver  des  transitions  brusques  dans  leur  mai6re 
d'etre,  la  nature  a  du  former  les  femmes  d'une  trempe  molle, 
pour  les  mettre  en  etat  de  resister  aux  orages  auxquels  elle  sont 
expose'es,"  p.  39,  vol.  i. 

Besides  the  system  just  enumerated  as  belonging  to  the  human 
system,  many  are  disposed  to  give  to  the  female  another,  namely, 
the  uterine  system ;  and  which  they  endow  with  an  extent  of  in- 
fluence that  belongs  to  no  other. 

It  has  been  handed  down  to  us  from  time  immemorial,  that  the 
uterus  exerts  a  paramount  power  over  every  other  system;  and 
governs  them  with  a  sway  no  less  whimsical  than  potent.  That 
it  creates,  exalts,  or  modifies  disease,  in  every  portion  of  the 
b'ody;  hence,  the  aphorism  of  Hippocrates,  "morborum  omnium 
qui  muliebres  vocantur  uteri  in  causS  sint."  That  it  not  only 
forms,  or  governs  the  moral  character  of  the  female,  but  regulates 
the  physioal  movements  of  her  body:  hence,  the  declaration  of 
Van  Helmont:  "propter  solum  uterum,  est  mulier  id  quod  est." 

By  many,  the  uterus  has  been  declared  to  possess  a  separate 
and  peculiar  life ;  that  it  has  its  own  mode  of  existence ;  and  is 
totally  independent  of  the  laws  which  govern  the  other  portions 
of  the  system.  Aretseus  compared  it  to  "an  animal  confined 
within  another  animal;  that  it  travelled  without  restraint  from 
any  portion  of  the  body  to  another;  that  it  would  take  possession 
of  any  sense;  or  occupy  any  viscera,  whether  situated  at  the 
right  or  the  left  side  of  the  body ;  but  that  its  movements  were 
rather  towards  the  inferior  portions  of  it.  It  was  like  a  wander- 
ing being;  that  it  relished  agreeable  odours,  and  would  move 
itself  towards  the  place  from  which  they  appeared  to  emanate ; 
but  would  remove  itself,  in  sadness,  from  places  which  had  disa- 
greeable smells,"  &C.1 

Sydenham,  Cullen,  Good,  and  very  many  others,  have  given 

'  Chambon. 


22  PECULIARITIES   OF 

to  this  organ  power  to  produce  or  modify  disease.  To  venture 
an  opinion,  that  would  very  much  differ  from  the  sentiments  of 
the  great  men  just  named,  would  have  the  appearance,  of  fastidi- 
ousness at  least,  if  not  of  rashness.  But,  as  we  have  never  wit- 
nessed any  decided  instance  of  this  exclusive  influence  of  the 
uterus  in  the  production  or  modification  of  disease,  we  feel  our- 
selves justified  in  entering  our  protest  against  its  possessing  such 
unlimited  sway.  In  doing  this,  however,  let  us  make  ourselves 
as  clearly  understood  as  the  nature  of  the  thing  will  permit. 

First. — We  have  ever  found  the  unoccupied  uterus  to  be  one  of 
great  passiveness  when  in  a  state  of  perfect  health ;  and  that  so 
long  as  it  preserved  this  condition,  it  manifested  no  agency  in 
the  production  of  disease,  or  in  modifying  it,  when  present.  Thus, 
fever,  inflammation,  either  local  or  general,  or  spasm,  has  never 
appeared  to  us  to  derive  advantage,  or  suffer  inconvenience,  from 
the  influence  of  this  organ. 

Second. — That  when  in  a  state  of  disease,  we  have  found  several 
parts  of  the  body  sympathize  with  the  uterus :  as  the  stomach, 
the  head,  the  breast,  &c.;  but  precisely  the  same  thing  may  be 
said  of  other  parts  of  the  body ;  yet  for  neither  of  these  is  such 
influence  claimed,  as  is  bestowed  upon  the  uterus.  Thus  the 
brain,  the  stomach,  the  kidneys,  the  liver,  &c.,  when  in  a  diseased 
state,  will  have  particular  parts  deranged  by  a  sympathetic  influ- 
ence ;  yet  it  has  never  been  asserted,  that  either  of  these  parts 
had,  at  any  other  time,  or  under  any  other  circumstance  but  disease, 
an  agency  in  producing  or  modifying  the  affections  of  other  portions 
of  the  body. 

Third. — While  the  uterus  is  performing  one  of  its  functional 
duties,  namely,  forming  the  menstrual  fluid;  when  it  is  known  to 
be  in  a  state  of  excitement,  and  decidedly  engorged  with  blood ; 
a  time  when  it  would  most  likely  exert  an  influence,  if  it  really 
possessed  any,  we  never  find  this  organ  exerting  a  power  over 
other  parts,  so  long  as  the  functional  process  is  carried  on  healthi- 
ly; and  during  this  period,  we  have  hitherto  not  been  able  to  de- 
tect the  slightest  influence  over  any  disease,  that  may  have  been 
present  in  the  system ;  nor  has  it  ever  made  us  vary  a  prescription, 
or  modify  a  treatment. 

Fourth. — That  when  the  menstruous  function  is  performed 
with  pain  and  difficulty,  other  portions  of  the  system  are  found 
to  suffer  from  sympathy;  but  in  no  greater  degree  than  these 
very  parts  have  been  known  to  suffer,  when  some  other  organ 
was  the  seat  of  irritation.  In  dysmenorrhoea,  we  have  known  the 
back  and  stomach  suffer  severely,  the  first  from  pretty  intense  pain, 
and  the  second  by  severe  vomiting;  but  we  have  seen  the  same 
consequences  attend  an  irritated  kidney,  or  an  inflamed  neck  of 
the  bladder. 

Fifth. — That  when   this  organ  is  labouring  under  severe  dis- 


THE    FEMALE   SYSTEM.  23 

ease,  as  inflammation,  scirrhus,  or  cancer,  "where  all  its  ordinary 
functions  are  either  deranged,  perverted,  or  suspended,  and  this 
for  a  long  period  together,  we  do  not  find,  that  it  involves  the 
system  in  any  severer  penalties  than  any  other  equally  important 
viscus  would,  under  similar  circumstances. 

Sixth. — That  when  its  functional  processes  are  irregularly  and 
imperfectly  performed;  or  are  altogether  suspended;  if  the  gene- 
ral health  suffer  from  this  cause,  it  is  not  because  the  uterus  has 
any  superior  power  to  effect  this,  but  because  a  link  is  broken 
(and  we  are  willing  to  admit  it  to  be  an  important  link,)  whereby 
the  chain  of  healthy  functions  is  maintained.  A  similar  condition 
of  any  of  the  other  viscera  would  be  followed  by  the  same  conse- 
quences. 

Seventh. — That  when  the  uterus  is  impregnated,  various  other 
portions  of  the  system  are  deranged,  in  consequence  of  their 
strong  sympathy  with  this  organ ;  but  even  here,  the  complaints 
are  not  sui  generis;  for  every  one  of  them  can  be,  and  have  been, 
very  often  similated  from  other  causes.1  The  whole  phenomena 
of  impregnation  are  so  well  understood  as  not  to  require  reciting; 
but  has  not  almost  every  body  witnessed  the  whole  train  of  these 
morbid  sympathies  to  arise  from  very  different  causes? 

We  would  then  ask,  what  evidence  is  there,  that  the  uterus 
possesses  such  unlimited  sway  over  the  healthy  or  diseased  move- 
ments of  almost  every  other  portion  of  the  body?  Does  not  this 
error  proceed  from  the  influence  of  authority,  and  a  supineness 
and  indifference  to  rational  inquiry  or  correct  observation  ?  Should 
the  names  of  Hippocrates,  Galen,  Aretseus,  Van  Helmont,  and  a 
hundred  others  of  greater  or  less  authority,  be  permitted  so  to 
satisfy  the  judgment,  or  so  paralyze  exertion,  as  to  prevent  all 
investigation  ? 

The  discoveries  of  Gall  and  Spurzheim  on  the  influence  of  the 
cerebral  system  upon  other  portions  of  the  body,  render  it  much 
more  probable,  that  the  various  morbid  phenomena  attributed  to 
the  influence  of  the  uterus,  depend  upon  certain  excitements  in 
the  cerebellum ;  and  that  the  several  facts  recorded  as  belonging 
to  the  genital  system  of  the  female,  are  themselves  but  evidences 
of  the  influence  of  cerebral  irritation.  In  the  male,  at  least,  this 
point  is  pretty  well  settled — as  it  has  been  found  by  Larrey  and 
others,  that  certain  wounds  or  injuries  of  the  cerebellum,  entail 
impotence.  It  is,  therefore,  much  more  rational  to  look  for  some 

1  In  this  assertion,  we  do  not  mean  to  include  that  beautiful  and  magic-like  play 
of  sympathies,  which  is  established  for  the  future  welfare  of  the  expected  being; 
namely,  the  swelling  of  the  mammae,  and  the  secretion  of  milk.  These  parts  have 
a  mutual,  and  an  associated  sympathy,  which  they  with  great  fidelity  maintain  as 
long  as  they  are  capable  of  performing  their  appropriate  functions.  The  nature 
and  extent  of  these  intercommunions  are  too  well  known  to  need  a  particular  men- 
tion. 


24  PECULIARITIES    OP    THE    FEMALE    SYSTEM. 

disturbance  of  the  brain  or  nervous  system,  as  long  since  suggested 
by  Willis,  for  the  origin  of  hysteria,  &c.,  than  to  any  direct  influ- 
ence of  the  uterine  system. 

Do  not  let  it  be  understood,  from  -what  we  have  just  said,  that 
we  undervalue  the  importance  of  the  uterus  as  an  organ  ;  for  as 
an  organ  we  are  free  to  admit  that  it  has  high  destinies  to  fulfil  ; 
we  only  wish  to  insist  that  it  has  no  exclusive,  or  concurrent 
power,  to  produce,  modify,  exalt,  or  dimmish,  any  disease  or  af- 
fection of  the  body,  beyond  several  other  viscera;  and,  perhaps, 
less  than  some.  The  stomach,  decidedly,  and,  perhaps,  the  liver, 
have  a  more  marked  influence,  either  in  a  state  of  health,  or  of 
disease,  over  the  animal  economy,  than  the  uterus. 

Nor  are  we  to  be  supposed  to  countenance  the  opinions  ad- 
vanced by  Mr.  Fogo,1  some  few  years  since,  in  a  paper  entitled, 
"  On  the  degree  of  importance  which  should  be  attached  to  the 
functions  of  the  uterus,  in  regard  to  health."  He  declares  it  as 
his  opinion,  that  the  uterus  is  of  so  little  consequence  to  the  ani- 
mal economy,  that  it  might  be  spared  from  the  body,  without  the 
system  suffering  by  its  removal.  He  calls  it  "  a  simple,  passive, 
accommodating  organ  ;  and,  on  this  account,  can  have  but  little 
influence  or  control  upon  the  functions  of  the  body."  If  the  value 
of  an  organ  be  tested  by  such  estimates,  to  what  a  low  value 
would  the  brain  or  the  stomach  be  reduced  ? 

The  stomach  may,  especially,  be  called  "a  simple,  passive, 
accommodating  organ;"  possessing,  perhaps,  in  a  greater  degree, 
these  qualities,  than  even  the  uterus  itself.  In  the  first  place,  its 
structure  is  less  complicated  than  the  uterus  ;  it  is  equally  pas- 
sive, when  permitted  to  be  so  ;  and  it  is  doubtless  as  "  accom- 
modating;" as  the  efforts  of  the  gourmand  have  frequently  proved. 
Yet  Mr.  Fogo,  himself,  would  not  hesitate  to  admit,  that  this 
"simple,  passive,  accommodating  organ,"  cannot  well  be  spared, 
because  it  possesses  these  qualities. 

In  a  word,  we  are  of  opinion,  that  the  uterus  ranks  in  the  first 
order  of  the  viscera  ;  that  its  health  is  every  way  important  to 
the  general  health  of  the  system  ;  but  that  it  does  not  exert  any 
particular  power  over  other  portions  of  the  body,  more  than  any 
other  important  viscus  would,  under  the  same  circumstances  ; 
namely,  of  disease.  That  its  influence  is  greatest,  while  performing, 
or  giving  evidence  of  its  best  state  of  health;  namely,  during 
gestation. 

'  See  an  answer  to  Mr.  Fogo's  paper,  in  "Essays  connected  with  Midwifery," 
by  William  P.  Dewees,  M.  D.,  &c. 


DISEASES   OF   EXTERNAL   AND   INTERNAL   ORGANS.      25 


CHAPTER   II. 

.  AVi/L  'i&m.v.ytL  vAv  v>  fc^Ksvfc/.'-:  -M  L*i*  «»<>$*&  ¥>—-.!.  .-i^?. 

OP  THE  DISEASES  OF  THE  EXTERNAL  AND  INTERNAL  ORGANS. 

THE  structure  of  the  external  organs  is  such  as  to  render  them 
liable  to  a  variety  of  complaints  that  always  excite  alarm,  how- 
ever free  they  may  be  from  danger.  Indeed,  any  disease  of 
these  parts  creates  a  great  deal  of  apprehension,  especially  in  the 
married,  or  the  pregnant  woman.  Women,  especially  the  mar- 
ried, are  often  kept  in  a  state  of  great  anxiety,  when  labouring 
under  any  affection  of  these  parts,  until  they  can  be  assured  it  is 
not  one  of  a  particular  kind,  and  that  it  will  not  be  attended 
with  danger.  On  this  account,  it  is  of  consequence  to  the  young 
practitioner,  that  he  be  acquainted  with  their  general  diseases, 
both  in  the  unimpregnated  and  in  the  impregnated  state  of  the 
uterus. 

It  may  be  observed,  as  a  general  rule,  with  respect  to  the  eco- 
nomy of  these  parts,  that,  from  their  great  vascularity  and  sensi- 
bility, inflammation  runs  on  very  rapidly  to  suppuration,  and  is 
accompanied  with  much  pain.  Indeed,  we  have  seen  severe  in- 
flammation of  the  labia  terminate  very  rapidly  in  gangrene,  though 
much  exertion  had  been  made  to  prevent  it.  It  may,  also,  be 
observed,  that  suppuration  of  the  labia  is  attended  with  more  than 
a  usual  degree  of  fetor;  owing,  most  probably,  to  their  very 
cellular  structure  ;  this  tissue  is  found  to  die  more  easily  when 
much  accumulated,  than  when  in  more  spare  proportions.  We 
may  also  add,  that  parts  thus  organized  granulate  more  slowly 
after  suppuration,  than  many  other  portions  of  the  body,  from  the 
same  cause. 

From  the  looseness  of  the  texture  of  some  of  these  parts,  espe- 
cially the  nymphae  and  labia.  they  become  sometimes  very  much 
enlarged,  from  very  slight  irritation  ;  and  when  there  has  been  a 
neglect  of  proper  cleanliness,  the  natural  secretions  become  acrid 
from  stagnation,  and  produce  itching,  which,  though  slight  at 
first,  very  much  increases  by  the  indulgence  of  scratching  ;  and 
if  this  be  persisted  in  the  parts  become  inflamed,  and  sometimes 
swell  inordinately,  but  does  no  mischief  ordinarily,  if  not  too  long 
persevered  in.  This  happens  especially  with  those  who  have  a 
dread  of  water  after  the  catamenial  discharge;  and  who  neglect 
to  wash  themselves  after  these  purgations.  On  this  account  it, 
is  important  that  the  parts  should  be  daily  washed  with  warm 
water,  particularly  during  the  flow,  and  immediately  after  the 
menses  have  ceased;  or  if  the  woman  be  subject  to  fluor  albus. 


26  DISEASES   OP   THE   NYMPH2B. 

The  prejudice  of  some  women  on  the  subject  of  washing,  should 
be  removed,  by  the  practitioner  making  it  a  point  to  recommend 
its  frequent  use,  when  consulted  on  these  diseases. 


SECT.  I.  —  Of  Tumours  and  Excrescences  of  the  External  Parts. 

Some  parts  of  the  external  organs  are  more  liable  to  tumours 
and  excrescences  than  others  ;  thus,  the  labia  and  nymphse  are 
more  frequently  the  seats  of  these  affections  than  other  portions 
of  the  vestibuluni.  The  nymphse  appear  more  obnoxious  to  in- 
durations and  excrescences,  than  even  the  labia;  and  they  are 
especially  so,  when  they  are  sufficiently  long  to  protrude  beyond 
the  labia. 


SECT.  II.  —  Diseases  of  the  Nymplise. 

When  these  bodies  become  much  enlarged,  they  present  a  very 
dark  colour*  are  dense,  and  sometimes  studded  with  a  number 
of  little  tumours  resembling  warts.2  From  their  position,  they 
are  constantly  liable  to  irritation  ;  and  in  cold  weather,  to  excoria- 
tion. Sometimes  violent  inflammation  seizes  upon  these  parts  in 
consequence  of  the  reaction  which  follows  a  great  reduction  of 
temperature. 

In  such  cases  rest  should  be  enjoined  ;  a  free  purging  insti- 
tuted; and  if  the  arterial  system  become  involved,  blood  should 
be  taken  from  the  arm  ;  or  from  near  the  part,  by  leeching.  A 
soft  bread  and  milk  poultice  should  be  applied  to  the  part,  and 
renewed  as  frequently  as  occasion  may  require  ;  that  is,  in  warm 
weather,  every  three  or  four  hours  ;  in  cool  or  cold  weather,  more 
seldom. 

These  parts,  from  the  intensity  of  the  inflammation,  (especially 
if  they  have  been  much  irritated  by  scratching,)  sometimes  run 
on  to  suppuration.  When  this  takes  place,  they  must  be  treated 
as  any  other  suppurating  surface  ;  taking  care  that  the  labia  are 
not  permitted  to  coalesce  during  the  healing.  We  once  saw  an 
instance  of  the  nymphae  suppurating,  and  by  this  means  getting 
rid  of  a  number  of  warty  excrescences,  with  which  they  had  been 
studded. 

Should  these  excrescences  attend  or  follow  a  venereal  affec- 
tion, it  might  be  well,  in  some  instances  where  the  disease  is 
obstinate,  to  try  the  effect  of  mercury;  but  this  remedy  holds  out 
but  little  prospect  of  success,  unless  there  be  present  an  unsub- 

1  Mr.  Burns  says  white;  but  this  we  have  never  seen. 

a  Duges  says  he  has  seen  them  from  the  size  of  a  pea  to  that  of  a  turkey's  egg. 
We  have  never  seen  any  so  large  as  the  latter. 


DISEASES    OF    THE    NYMPHJE.  27 

dued  venereal  taint.  When  they  are  in  the  form  of  warts,  and 
these  very  numerous,  as  is  the  case  very  often,  nothing  will  suc- 
ceed so  well  as  keeping  the  parts  very  dry,  and  exposed  as  much 
as  possible  to  the  air.  The  following  case  will  illustrate  this 
practice  sufficiently. 

Mrs.  had  been  severely  injured  by  her  husband  giving 

her  the  venereal  disease  in  its  most  aggravated  form ;  namely, 
chancres  and  buboes.  About  six  months  after  she  appeared  to 
have  recovered  from  these  affections,  she  found  a  vast  number  of 
little  tumours  spread  over  the  labia,  the  nyraphse,  and  other  por- 
tions of  the  vulva,  which  increased  rapidly  in  number  as  well  as 
augmented  in  size;  from  the  whole  surface  of  which  there  issued 
a  disagreeable  smelling  matter  which  excited  itching;  and  when 
the  parts  were  rubbed,  blood  would  follow. 

The  gentleman  who  had  attended  this  patient  for  the  venereal 
complaint,  was  called  on  again  on  account  of  the  warts;  he  pre- 
scribed mercury  to  salivation :  this  was  complied  with ;  but  the 
little  warty  tumours  increased  to  such  an  extent,  that  a  severe 
bleeding  would  follow  every  attempt  at  conjugal  enjoyment.  We 
were  now  consulted.  The  whole  vulva  was  found  to  be  completely 
occupied  by  these  warty  productions ;  and  were  almost  without 
number,  and  of  great  variety  of  sizes.  As  we  had  treated  these 
productions  in  the  male  with  success  by  exposing  them  to  the  air 
and  keeping  them  perfectly  dry,  it  was  agreed,  that  our  patient 
should  follow  this  plan. 

The  patient  was  ordered  to  bed,  and  the  labia  were  kep't  sepa- 
rate, by  means  of  adhesive  plaster:  this  being  done,  the  whole 
vestibulum,  and  crop  of  warts,  were  exposed.  A  quantity  of 
prepared  chalk  was  dusted  upon  the  surface,  and  no  other  appli- 
cation was  permitted  if  we  except  the  occasional  washings  with 
warm  water,  to  remove  the  incrusted  chalk;  that  is,  morning  and 
evening.  This  plan,  though  a  little  difficult  of  accomplishment, 
succeeded  in  about  a  fortnight  to  remove  every  excrescence,  so  as 
not  to  leave  a  vestige  behind. 

It  was  truly  remarkable  to  see  with  what  rapidity  these  para- 
sitic productions  lost  their  lives,  by  depriving  them  of  moisture. 
They  would  drop  off  in  large  portions  at  every  bathing  of  the 
parts,  until  all  perished  in  turn. 

Besides  the  excrescences  just  noticed,  these  parts  are  subject 
to  prodigious  enlargements ;  and  sometimes  require  the  knife  for 
their  removal.  There  is  a  preparation  of  this  kind  in  the  Museum 
of  the  Medical  College  of  Pennsylvania,  of  an  enormous  size,  and 
well  worth  the  trouble  of  an  examination. 

The  extirpation  of  these  tumours  is  considered  by  all  surgeons, 
we  believe,  to  be  perfectly  safe.  The  operation  never  seems  to 
expose  any  large  vessels.  And  Dr.  Denman  informs  us,  he  has 
seen  the  enlarged  nymphae  and  excrescences  removed  by  the  knife, 


28  DISEASES   OF   THE   CLITORIS. 

without  the  necessity  of  tying  a  single  blood-vessel.      Introd. 
Francis's  ed.  p.  100. 

In  certain  parts  of  the  world,  the  nymphse  are  peculiarly  lia- 
ble to  enlargement;  in  some  instances  they  have  measured  seve- 
ral inches,  as  among  the  Bosjesman  women,  if  the  accounts  of 
travellers  are  to  be  depended  upon.  On  the  shores  of  the  Persian 
gulf,  the  Christian  women  of  Abyssinia,  and  in  parts  of  Egypt, 
the  girls  have  these  parts  removed  as  a  ceremony :  it  is  intended 
to  resemble  circumcision. 


SECT.  III. — Diseases  of  the  Clitoris. 

The  clitoris^ias  occasionally  been  the  seat  of  scirrhus,  and  of 
cancer,  but  when  either  of  these  seize  the  part,  the  cure  is  hope- 
less, unless  the  whole  of  the  disease  can  be  removed  by  an  ope- 
ration. In  the  Medical  and  Physical  Journal,  vol.  v.,  p.  1,  Mr. 
Simmons  relates  a  case  of  enlarged  clitoris,  which  he  removed 
by  excision,  which  measured  in  length  nine  inches  j  while  the  cir- 
cumference of  the  stem  measured  five.1 

It  is  the  augmentation  of  this  part,  and  especially  when  it  as- 
sumes an  equivocal  form,  that  has  given  rise  to  the  absurd  opinion 
of  hermaphrodites.  It  occurs  most  frequently  in  hot  climates. 
We  have  seen  a  number  of  instances  in  new-born  children,  where 
this  part,  as  well  as  the  nymphae,  have  stood  entirely  without 
the  labia.  Whether  these  parts  increased  in  the  same  propor- 
tion as  the  body  enlarged,  we  have  never  had  an  opportunity  to 
ascertain. 

The  existence  of  the  hermaphrodite  has  gained  the  assent  of 
the  greater  part  of  mankind ;  so  much  so,  that  it  would  be  diffi- 
cult to  disabuse  them :  we  shall,  therefore,  not  attempt  it.  To  the 
physician,  frequent  appeals  are  made  for  his  opinion  on  this  sub- 
ject, and  he  too  often  yields  to  the  popular  belief;  but  he  should 
be  informed,  that,  so  far,  no  well-attested  instance  of  this  com- 
pound of  sexes  has  ever  been  produced  in  the  human  subject. 
A  resemblance  in  conformation  does  not  prove  identity  of  func- 
tion ;  and,  consequently,  the  general  similarity  of  appearance,  be- 
tween the  clitoris  of  the  female  and  the  penis  of  the  male,  how- 
ever striking,  does  not  prove  them  to  be  intended  for  the  same 

1  "  A  clitoris  was  amputated  some  time  ago  in  Mercer's  Hospital,  in  this  city. 
(Dublin)  which,  in  volume,  was  about  equal  to  the  head  of  a  child  of  two  years 
old."  Churchill's  Diseases  of  Females,  p.  25,  Am.  Ed. 

Diseases  of  this  part,  from  the  gratification  experienced  by  rubbing  or  scratching, 
have  led,  according  to  Mr.  Churchill,  to  the  establishment  of  Nymphomania,  p. 
17.  The  frequent  mention  of  this  complaint  has  induced  me  to  the  belief,  that  it  is 
no  uncommon  occurrence  in  both  Great  Britain  and  France,  but  which  is  surely  not 
the  case  in  this  country. 


ADHESION  OP  THE  LABIA  PUDENDI.         29 

purposes.  And  it  may  be  observed,  that  this  similarity  is  more  in 
the  external  form,  than  in  the  internal  structure. 

Nor  do  the  instances  in  other  mammalia,  purporting  to  be  of 
the  same  kind,  afford  the  slightest  support  to  this  opinion.  For, 
perhaps,  every  instance  hitherto  examined  has  proved  to  arise 
from  a  defect  in  the  arrangement  or  organization  of  the  sexual 
organs.  Besides,  in  the  higher  classes  of  animals,  it  does  not 
comport  with  the  general  analogy  of  nature,  that  one  should  pos- 
sess the  generative  powers  of  both  sexes. 

Dr.  Francis  informs  us,  that  "the  latest  decisions  in  juridical 
medicine,  reject  the  possibility  of  both  sexes  in  the  same  indivi- 
dual of  the  human  species."  * 


SECT.  IV. — Of  Adhesion  of  the  Ldbia  Pudendi  of  Children. 

The  labia  pudendi  of  young  children  are  very  often  found  ad- 
herent. This  may  be  congenite ;  but  we  believe  it  to  be  very 
rarely  so.  We  have  seldom  seen  this  condition  of  the  parts,  in 
children  under  six  months  old;  and  still  more  rarely,  after  the 
age  of  a  year.  From  these  facts,  it  would  seem  to  be  almost 
always  adventitious,  and  owing  principally  to  a  want  of  cleanli- 
ness. Had  the  child  been  born  with  the  labia  in  this  condition, 
it  is  more  than  probable  it  would  have  been  discovered  early,  as 
nurses,  generally  speaking,  are  at  least  curious,  if  not  always 
careful. 

When  we  consider  the  delicacy  and  vascularity  of  the  mem- 
brane lining  the  internal  face  of  the  labia;  the  ease  with  which 
inflammation  is  provoked  in  parts  so  organized ;  when  we  recol- 
lect how  quickly  the  secretions  of  the  parts  become  acrid,  where 
proper  attention  to  cleanliness  is  not  bestowed  upon  them ;  and  how 
readily  a  slight  inflammation  may  be  increased  by  the  flow  of 
urine;  we  shall  cease  to  wonder  at  the  frequency  of  this  com- 
plaint, and,  perhaps,  be  even  surprised  that  it  does  not  occur 
oftener. 

We  have  reason  to  believe,  that  in  many  instances,  this  com- 
plaint had  existed  some  time  before  it  was  discovered :  this  may 
especially  be  the  case  with  fat  or  lusty  children,  and  where  the 
most  scrupulous  attention  is  not  constantly  paid  to  the  condition 
of  these  parts.  Therefore  it  must  be  looked  upon,  in  general,  as 
arising  from  a  reprehensible  neglect;  for  it  is  the  bounden  duty  of 
every  mother,  however  averse  she  may  be  from  the  performance  of 
it,  to  carefully  inspect  these  parts  from  time  to  time ;  particularly 
until  the  child  is  fifteen  or  eighteen  months  old,  in  order  that  the 

'Denman,  p.  106. 


30  ADHESION    OP    THE    LABI  A    PUDENDI. 

inconvenience  under  consideration  may  not  take  place;  or  if  it 
have,  that  it  may  be  detected  early. 

Parents  should  direct,  and  the  performance  should  be  insisted 
on,  that  these  parts  be  regularly  cleansed  every  time  the  child  is 
washed,  by  carefully  separating  the  labia,  and  applying  water 
liberally  to  them;  they  should  then  be  tenderly  dried  with  a  soft 
linen  cloth,  and  dusted  with  hair  powder,  or  powdered  starch,  in 
which  there  is  no  blue.  If  this  were  regularly  done  in  early  in- 
fancy, the  parts  would  become  so  hardened  as  to  diminish  the 
risk,  very  much,  of  its  taking  place  after  less  attention  is  paid  to 
them. 

We  have  dwelt  upon  this  subject,  because  we  know  its  impor- 
tance; and  because  it  has  not  sufficiently  attracted  attention. 
Sometimes,  unfortunately  for  the  female,  it  has  not  been  discovered 
during  infancy  ;  and  it  is  especially  unfortunate,  when  it  remains 
concealed  until  womanhood ;  when,  perhaps,  the  first  intimation 
she  may  receive  of  her  situation,  is  at  a  time,  when  of  all  others 
she  would  wish  to  have  been  ignorant  of  it.  The  alternative,  now, 
subjects  her  to  an  operation,  which  should  have  been  performed  in 
early  life. 

This  complaint  sometimes  becomes  relieved,  spontaneously. — 
This  occurs,  probably,  more  frequently  than  we  are  aware  of ;  as 
the  causes  which  may  produce  it  are  so  constantly  operating,  as 
to  lead  us  to  suppose  this  accident  to  exist  in  cases  where  it  has 
not  been  detected.  We  have  had  two  instances  of  this  sponta- 
neous change  to  happen  under  our  own  observation. 

In  one  of  these,  there  was  so  much  inflammation  and  tender- 
ness in  the  parts,  that  we  did  not  think  it  advisable  to  operate, 
until  the  existing  state  of  things  was  changed.  We  directed  soft 
bread  and  milk  poultices,  and  a  cathartic.  On  our  next  exami- 
nation, we  found  that  a  complete  separation  had  taken  place,  by 
the  adhering  parts  having  suppurated.  Two  raw  surfaces  were 
now  exposed,  which  required  much  attention  to  prevent  reunion  in 
healing. 

The  other  case  was  something  similar :  suppuration  had  com- 
menced, and  the  connecting  medium  was  nearly  destroyed,  when 
it  was  first  observed.  It  was  poulticed  as  in  the  other  case  ; 
and  when  about  to  heal,  care  was  taken  to  prevent  a  second  coa- 
lescence. 

This  condition  of  the  labia  is  easily  detected  by  their  refusing 
to  be  separated  when  the  attempt  is  made  for  this  purpose.  For 
when  the  labia  are  separated  by  force  as  much  as  their  condition 
will  permit,  a  continuous  line  of  union  will  be  observed  through 
their  whole  track ;  that  is  from  the  meatus  urinarius  posteriorly, 
and  to  the  fourchette  below ;  of  course,  the  os  externum  is  entire- 
ly concealed.  The  child  passes  its  water  with  some  little  difficul- 


ADHESION    OF    THE    LABIA    PTJDENDI.  31 

ty ;  and  when  the  complaint  has  been  suffered  to  run  on,  or  not 
discovered  until  womanhood,  the  menstruous  fluid  is  evacuated 
through  the  same  external  aperture  by  which  the  urine  is  dis- 
charged.1 

There  is  but  one  remedy,  that  we  know  of  for  this  complaint 
— and  that  is  dividing  the  parts.  This  is  very  easily  performed, 
by  passing  a  probe-pointed  bistoury  into  the  orifice  immediately 
before  the  meatus  urinarius,  and  cutting  downward  to  the  infe- 
rior junction  of  the  labia.  A  small  dossil  of  lint,  moistened  with 
sweet  oil,  may  be  insinuated  between  the  separated  portions. 
The  wound  heals,  without  the  smallest  difficulty,  in  two  or  three 
days. 

Dr.  Denman,  however,  gives  another  opinion  upon  this  subject : 
he  says,  "  In  such  cases,  we  have  been  directed  to  separate  them 
(the  labia)  with  a  knife ;  and  how  far  such  an  operation  may 
be  necessary  in  the  adult,  if  the  parts  should  cohere,  either  in 
consequence  of  some  new  affection,  or  if  a  cohesion,  originating  in 
infancy,  should  continue  to  adult  age,  must  depend  upon  the  judg- 
ment of  the  surgeon.  But,  in  infants,  such  an  operation  is  neither 
requisite  nor  proper  ;  because,  a  separation  may  always  be  made, 
by  a  firm  and  somewhat  distracting  pressure  upon  each  labium  at 
the  same  time,  which  scarcely  makes  the  child  complain ;  though 
the  small  vessels,  which  had  inosculated  from  one  labium  to  the 
other,  may  be  perceived  to  be  dragged  o,ut  during  the  continuance 
of  the  pressure.  When  a  separation  of  the  cohering  labia  has 
been  made  in  the  manner  before  mentioned,  a  folded  piece  of 
linen,  moistened  in  a  very  weak  solution  of  the  zincum  vitriolatum, 
or  some  slightly  astringent  liquor,  should  be  applied  every  night 
when  the  child  is  put  to  rest,  to  prevent  the  reunion,  to  which 
there  is  a  great  disposition."  Introduction  to  Midwifery,  Francis's 
Edition,  p.  101. 

We  cannot,  from  our  own  experience,  give  an  opinion  upon  the 
success  of  Dr.  Denman's  mode  of  operating  in  adhesions  of  the 
labia.  .  But  his  reputation  as  a  man  of  skill  and  judgment,  would 
justify  any  one  in  making  the  attempt  he  proposes;  though  we 
should,  ourselves,  not  be  induced  to  imitate  it.  The  little  pain, 
and  the  entire  success  which  has  followed  the  use  of  the  knife 
in  the  numerous  cases  we  have  employed  it,  give  our  mind  a 
strong  bias  in  its  favour.  A  preference  for  the  mode  recom- 
mended by  Dr.  D.,  can  only  arise  from  an  ill-founded  dread 
of  the  knife ;  it  would,  unquestionably,  have  required  violent  exer- 
tions to  have  torn  some  of  the  adhesions  we  have  seen;  and 

1  That  is,  there  is  no  other  outlet  for  the  discharges  from  the  uterus  but  that 
which  the  urine  has  preserved  for  itself;  and  by  this  often  passing,  it  prevents 
the  entire  adhesion  of  the  labia.  But  this  does  not  constitute  the  "imperforate 
hymen." 


32  'ABSCESSES  OF  THE  LABI  A. 

much  pain  and  inflammation,  we  think,  would  have  followed  such 
efforts. 

*  t       ' 

SECT.  V. — Abscesses  of  the  Lqbia. 

A  variety  of  causes  may  excite  inflammation  in  the  labia; 
and,  when  once  produced,  it  is  always  interrupted  with  difficulty; 
the  vascular  and  cellular  construction  of  these  parts  contributes 
much  to  hasten  the  suppurative  stage.  We  do  not  remember  a 
single  instance  in  which  a  phlegmonous  inflammation  terminated 
by  resolution,  though  in  several  instances,  the  chances  were  as 
fair  for  trial,  (from  the  early  application  of  the  patient  for  relief,) 
as  these  cases  generally  are.  Indeed,  our  failures  to  procure 
resolution  have  been  so  uniform,  that  of  late  years  we  do  not 
attempt  it;  on  the  contrary,  the  immediate  application  of  the 
ung.  hydrarg.  fort,  sine  tereb.,  or  a  warm  bread  and  milk  poul- 
tice, is  always  advised. 

The  progress  of  this  inflammation  to  suppuration  is  usually  so 
rapid,  that  but  little  time  is  permitted  to  make  an  attempt  to  pro- 
cure resolution.  The  suppurative  stage  we  have  known  to  take 
place  in  a  few  hours ;  and  it  seldom  continues  beyond  three  or 
four  days.1 

This  complaint  is  usually  announced  by  a  sense  of  heat,  or 
rather  of  burning,  in  one  of  the  labia,  and  if  it  be  touched,  even 
slightly,  pain  is  felt.  Pain  is  also  experienced  upon  any  motion 
which  employs  the  lower  extremities,  and  especially  upon  sitting 
down  or  crossing  the  legs.  The  internal  face  of  the  labium  is 
found  distended,  very  red,  and  protruding  beyond  the  external 
covering  of  this  part.  It  is  from  the  great  tenuity  of  this  internal 
membrane,  and,  on  this  account,  bearing  distention  so  ill,  that  we 
may  look  for  the  little  success  that  has  followed  either  general 
and  local  bleeding,  purging,  low  diet,  or  sedative  applications,  to 
prevent  suppuration. 

We  have  seen  these  abscesses  in  children,  in  several  instances, 
follow  bruises  of  these  parts;  they  seem  to  be  more  painful  in 
young  subjects  than  in  older ;  they  are  almost  always  accom- 
panied, in  children,  as  in  older  people,  by  fever;  and  require  a 
strict  antiphlogistic  treatment.  We  have  thought  the  application 
of  the  ung.  hydrarg.  fort,  sine  tereb.,  to  be  more  useful  than  poul- 
tices, especially  in  young  subjects;  as  it  is  always  difficult  to 
confine  a  poultice  to  the  parts  with  sufficient  exactness.  One  of 
the  most  painful  and  largest  abscesses  of  this  kind  we  remember 
to  have  seen,  arose  from  a  young  lady  sitting  down  suddenly 

*  "  This  disease  may  be  distinguished  from  Hernia  by  greater  firmness  of  the 
swelling,  and  its  more  circumscribed  character.  It  is  increased  by  coughing,  and 
is  not  reducible."  Churchill's  Principal  Diseases  of  Females,  p.  2. 


(EDEMA  TO  US    SWELLING    OF   THE    LABIA.  33 

upon  a  hard  pin-cushion  ;  this  case  was  treated  exclusively  with 
the  ointment,  until  the  moment  the  latter  was  discharged.  They 
sometimes  succeed  to  labour,  and  more  frequently  after  a  first 
child,  than  with  the  subsequent  ones;  unless  some  violence  has 
been  used  to  terminate  the  labour. 

From  the  great  delicacy  of  the  membrane  covering  the  internal 
face  of  the  vulva,  it  is  apt,  when  inflamed  and  much  distended, 
to  take  on  the  erysipelatous  form,  and  very  quickly  become 
vesicated;  and  if  not  soon  relieved,  will  often  slough.  On  this 
account,  we  have  been  in  the  habit,  for  some  years,  of  exclu- 
sively employing  the  mercurial  ointment  for  this  species  of  in- 
flammation. 

Notwithstanding  the  rapidity  with  which  matter  generally  forms, 
the  inflammation  is  sometimes  less  active;  requiring  a  number 
of  days  for  it  to  pass  through  its  stages.  When  this  happens, 
the  tumour  feels  like  a  moveable  gland  under  the  skin.  But  this 
lesser  rapidity  of  march  gives  but  little  additional  security  against 
suppuration;  for  this  will  take  place,  though  at  a  more  remote 
period. 

When  pain  is  considerable,  laudanum  must  be  given  ;  but,  un- 
fortunately, it  does  not  always  procure  rest.  These  abscesses  are 
not,  however,  in  every  instance  attended  by  severe  pain;  we  have 
known  them  discharge  themselves  with  very  little  inconvenience 
to  the  patient. 

It  has  been  taught  by  many,  that  these  abscesses  should  always 
be  permitted  to  break  spontaneously;  but  for  what  reason,  we  do 
not  perceive.  We  have  always  pursued  a  contrary  plan  when 
we  have  had  the  opportunity  ;  only  taking  care  that  the  lancet  is 
not  prematurely  employed.  It,  however,  does  not  often  require 
our  interference;  as  the  tumour  opens  of  itself  in  a  short  time; 
but  should  it  not,  we  do  not  hesitate  to  puncture  it,  if  the  suffer- 
ing be  great,  and  the  fluctuation  evident,  for  puncturing  is  all 
that  is  necessary,  unless  the  most  depending  part  of  the  tumour 
cannot  be  well  commanded:  in  this  case,  it  becomes  sometimes 
necessary  to  lay  it  open  to  some  distance,  in  order  to  secure  a 
favourable  healing. 


SECT.  VI.  —  (Edematous  Swelling  of  the  Labia. 

It  is  not  an  unfrequent  occurrence,  especially  with  pregnant 
women,  for  the  external  parts  to  swell,  or  become  cedematous. 
Women  who  have  borne  many  children,  and  who  labour  under 
the  anterior  obliquity  of  the  uterus,  are  more  liable  to  this  com- 
plaint, than  those  who  are  pregnant  for  the  first  time,  or  those 
who  have  not  this  obliquity.  Women  of  leucophlegmatic  habits, 
3 


34  (EDEMATOUS     SWELLING     OF     THE     LABIA. 

who  are  much  upon  their   feet,  and  who  may  he  disposed  to  ana- 
sarca,  are  also  more  subject  to  this  complaint  than  others. 

It  rarely  happens,  however,  that  this  affection  is  confined  to  the 
labia :  it  sometimes  pervades  the  whole  .  of  the  lower  extremities, 
to  a  very  troublesome  degree;  nay,  even  to  bursting. 

This  condition  creates  a  great  deal  of  alarm,  and  is  looked  upon 
as  a  genuine  dropsy.  Some  have  thought  it  promised  an  easy  la- 
bour ;  we  have  never  seen  this  connexion  ;  on  the  contrary,  when 
excessive,  we  have  thought  it  rather  retarded  this  operation,  by 
interfering  with  the  voluntary  exertions  of  the  woman,  and  the 
development  of  the  external  parts:  and  on  this  account  it  subjects 
the  labia,  and  perhaps  the  perineum,  to  laceration.  At  least  we 
witnessed  a  case  of  this  kind,  in  which  the  laceration  took  place, 
though  not  very  extensively.  The  midwife,  who  had  charge 
of  this  case,  said  she  could  account  for  it  in  no  other  way ;  as 
from  its  thickness  it  would  not  yield.  In  this  instance  also,  the 
labia  suffered  very  much  from  giving  way.  There  was  much  in- 
flammation of  the  erysipelatous  kind ;  and  considerable  sloughing 
followed,  attended  by  a  great  discharge  of  ill-concocted  pus,  or 
rather  of  sanies. 

This  case  has  made  me  attentive  to  these  swellings  before 
labour  is  expected,  whenever  consulted  for  them.  When  it  is 
purely  a  consequence  of  gestation,  it  will  sometimes  recede  of 
itself,  several  days  before  pain  shows  itself;  but  this  must  not  be 
relied  upon  always,  since  this  change  does  not  constantly  take 
place.  This  condition  of  the  labia  is  almost  sure  to  be  accom- 
panied by  a  full,  hard  pulse,  constipated  bowels,  and  paucity  of 
urine;  notwithstanding  that  these  swellings  have  their  origin  in  a 
mechanical  cause. 

We  have  sometimes  found  great  advantage  from  the  loss  of  & 
few  ounces  of  blood,  a  horizontal  posture,  and  twenty  grains  of 
nitre,  three  or  four  times  a  day;  taking  care  to  keep  the  bowels 
soluble  by  the  neutral  salts  in  small  doses.  If  it  be  evident,  from 
the  degree  of  swelling,  that  the  cutis  will  give  way  if  not  relieved, 
it  is  besttfo  take  off  the  distention  by  puncturing  such  parts  as 
are  most  in  danger;  when  the  labia  are  punctured,  it  should  be 
upon  their  internal  face. 

Should  it  arise  from  a  dropsical  disposition  in  the  general  sys- 
tem, little  can  be  done  towards  a  cure,  until  after  delivery  :  though 
it  must  be  constantly  proper  to  relieve  the  bursting  skin  by  punc- 
tures, should  labour  even  be  begun.  We  have  been  obliged  to  do 
this  in  several  instances,  before  the  finger  could  be  well  introduced 
into  the  vagina ;  nor  "have  we  ever  seen  the  least  inconvenience 
follow  the  practice. 

The  woman  should  be  directed  to  confine  herself  almost  entire- 
ly to  the  bed,  for  the  last  week  or  ten  days  of  her  time ;  and 


BLOODY    INFILTRATIONS,  ETC.  35 

she  must  be  put  upon  her  guard,  against  a  full  and  stimulating 
diet.     Indeed,  the  less  she  eats,  the  better. 


SECT.  VII. — Of  Bloody  Infiltrations  in  the  Labia  Pudendi. 

During  labour  a  variety  of  accidents  may  occur  to  the  parts 
concerned  in  this  operation,  among  which,  the  one  about  to  be 
noticed  is  not  the  least  formidable  in  appearance,  nor  the  least 
tedious  in  the  cure.  The  disease  to  which  I  allude  is  the  sud- 
den and  excessive  distention  of  the  labia  pudendi,  or  only  one  of 
them,  with  blood,  from  some  neighbouring  vessel  giving  way, 
either  during  the  progress,  or  very  quickly  after  the  delivery  of 
the  child;  or,  in  some  cases,  immediately  after  the  expulsion  of 
the  head. 

This  complaint  is  generally  confined  to  one  labium ;  I  have  never 
seen  it  otherwise,  though  cases  are  related  where  it  has  happened 
to  both.  Thus,  Baudelocque  mentions  a  case,  on  the  authority  of 
Solayres,  where  the  labia  were  equally  affected.  This  is  certainly 
not  usual ;  and  perhaps  may  be  accounted  for  from  the  peculiar 
nature  of  its  cause;  namely,  a  varicose  condition  of  the  veins  of 
the  labia  and  vagina. 

This  accident,  in  every  instance  in  which  I  have  witnessed  it, 
has  taken  place  after  the  delivery  of  the  child,  though  not  always 
immediately;  but  this  is  by  no  means  constant;  as  we  are  in- 
formed by  Drs.  Maitland  and  Perfect,  that  the  swelling  occurred 
before  the  child  was  delivered.  Dr.  Maitland  says,  in  his  patient, 
he  found  a  soft  tumour  covering  the  os  externum,  very  much 
resembling  the  distended  membranes,  which  proved  to  be  the 
right  labium  pudendi  distended  to  the  enormous  size  of  a  child's 
head. 

Dr.  Burns  is  of  opinion,  that  this  swelling  is  owing  to  the  rup- 
ture of  a  vessel  within  the  nymphae;  but  it  is  hardly  probable 
that  any  vessel  belonging  to  these  parts  would  yield  so  suddenly 
such  an  enormous  quantity  of  blood  as  is  sometimes  expended ; 
for  as  much  as  five  pounds  have  been  discharged.  In  this  case 
the  patient  died.  In  another  instance,  twenty  ounces  were  eva- 
cuated, £c.  See  Burns,  James's  Ed.,  p.  CO.  I  am  of  opinion, 
that  the  blood  proceeds  from  vessels  situated  rather  within  the 
vagina;  for  those  which  compose  the  vaginal  plexus,  immediately 
behind  the  corpus  spongiosum,  are  the  most  likely  to  suffer  during 
the  passage  of  the  child's  head,  and  to  furnish  this  large  quantity 
of  blood. 

And  this  opinion  appears  to  be  strengthened,  by  cases  in  which 
the  accident  happens  before  the  delivery  of  the  child;  as  the  part 
just  mentioned  will  suffer  distention,  before  the  head  has  entirely 
escaped  through  the  os  externum.  Dr.  Maitland  accounts  for 


86  BLOODY  INFILTRATIONS   IN 

this  case,  by  supposing,  that,  "  from  the  pressure  of  the  child's 
head,  and  the  violent  stretching  of  the  parts  during  the  labour 
pains,  some  of  the  small  vessels  had  hurst."  Med.  Comment., 
vol.  vi.,  p.  89.  Now  it  must  be  evident,  that  the  nymph<e  cannot 
be  put  upon  the  stretch  while  the  head  is  confined  within  the  pelvic 
cavity ;  and,  perhaps,  the  hardness  of  the  head  may  contribute  to 
the  occurrence  of  the  accident,  as  I  have  not  seen  or  found  re- 
lated, a  case  in  which  it  took  place,  where  any  other  part  had 
presented. 

The  vessels  which  furnish  the  blood  must  be  of  considerable 
size ;  as  the  tumour  which,  constitutes  the  disease  is  very  sud- 
denly formed,  and  is  oftentimes  enormous.  The  cases  which  I 
have  witnessed,  were  all  of  this  rapid  kind ;  occupying  but  a  few 
minutes  for  the  formation  of  the  tumour.  Mr.  Burns,  however, 
declares,  that  "  it  has  been  known  to  advance  so  slowly,  as  not 
to  attract  attention  for  two  days,"  p.  60.  This  may,  doubtless, 
have  happened,  since  the  rapidity  of  the  formation  of  the  tumour 
must  necessarily  depend  upon  the  size  of  the  number  of  the  ves- 
sels injured.  In  these  slow  cases,  mentioned  by  Mr.  Burns,  it 
may  have  arisen  from  the  rupture  of  a  vessel  in  one  of  the 
nymphsB. 

This  complaint  has  been  mistaken  for  the  distended  and  pro- 
truding membranes,  and  for  a  hernia ;  but  a  careful  examination 
of  the  deranged  part  will  soon  remove  these  errors.  For  it  ex- 
hibits neither  the  position  nor  the  colour  presented  in  either  of  the 
cases  with  which  it  has  been  confounded.  Its  position  is  lateral, 
unless  both  labia  are  involved;  in  which  case,  the  natural  sulcus 
must  be  observable;  and  its  colour  is  that  of  extreme  lividit}r, 
or  entirely  black,  which  resembles  neither  the  membranes  nor 
hernia. 

Owing  to  the  unequal  density  of  the  external  covering  and  in- 
ternal face  of  the  labium,  it  becomes  irregularly  distended ;  and 
scarcely  any  thing  is  seen  but  its  excessively  stretched,  internal 
surface.  So  much  so  is  this  the  case,  that  Dr.  Maitland  tells  us, 
in  the  instance  he  witnessed,  "  the  inside  of  the  labium  was  turned 
So  much  outwards,  that  on  the  first  application  of  the  hand,  the 
skin  and  hairs  of  the  part  were  not  felt." 

The  internal  lining  of  the  labium  gives  way  sometimes  from 
the  excessive  distention  it  has  been  made  to  suffer;  this  permits 
a  quantity  of  fluid  blood  or  a  few  coagula  to  escape,  which  tends 
very  much  to  diminish  the  extreme  anguish  of  the  patient.  In 
all  instances  of  this  kind,  much  pain  is  endured;  and,  in  some 
cases^it  has  been  so  severe  as  to  cause  syncope:  a  case  of  this 
kind  is  related  by  Dr.  Reeve,  in  the  ninth  volume  of  the  London 
Medical  Journal.  Sometimes  the  tumour  bursts  before  the  child 
is  born ;  Dr.  Perfect  relates  a  case  of  this  kind;  and  the  first  case 
related  below  may  be  considered  as  a  similar  instance. 


THE    LABIA    PUDENDI.  37 

But,  if  this  bursting  does  not  take  place,  as  sometimes  happens 
when  the  size  of  the  tumour  is  not  enormous,  the  internal  face  of 
the  labium  is  sure  to  yield  in  a  short  time,  from  gangrene  taking 
place  through  its  whole  extent.  This  condition  has  been  pre- 
ceded, in  two  of  the  cases  I  have  witnessed,  by  innumerable  vesi- 
cations  containing  a  yellowish  serum,  spreading  themselves  over 
the  whole  surface  of  the  tumour,  formed  by  the  stretching  of  the 
internal  membrane  of  this  part,  but  which,  very  soon  after  the 
swelling  has  acquired  considerable  size,  yields,  from  the  loss  of 
life ;  and  the  patient  in  consequence  feels  considerable  relief. 

When  the  part  sloughs,  it  exposes  a  large  surface  of  coagulated 
blood,  which  quickly  becomes  decomposed,  and  yields  a  stench 
that  is  altogether  intolerable. 

Should  the  parts  not  give  way,  the  pain  arising  from  disten- 
tion  is  unceasing  and  truly  agonizing ;  fever  of  a  very  active  kind 
is  quickly  kindled;  delirium  sometimes  attends,  and  the  woman's 
life  becomes  severely  threatened.  Her  sufferings  are  also  aug- 
mented by  the  retention  of  urine;  as  its  passage  is  prevented  by 
the  tumour  pressing  firmly  against  the  meatus  externus  of  the 
urethra.  The  patient  can  lie  only  upon  her  back,  with  her  knees 
drawn  up,  and  the  thighs  widely  separated.  She  cannot  bear 
the  pressure  of  the  bed-clothes,  nor  the  lightest  applications; 
therefore  it  is  in  vain  to  offer  relief,  until  the  distended  parts  yield 
spontaneously,  or  are  made  to  do  so,  by  artificial  means. 

The  severity  of  the  patient's  sufferings  call  for  prompt  and 
efficient  relief:  this  must  be  administered  by  both  general  and 
local  means.  If  fever  attend,  blood-letting  must  be  employed  to 
an  extent  that  will  ensure  the  reduction  of  arterial  action ;  and 
be  repeated  pro  re  nata.  With  a  view  to  give  the  earliest  oppor- 
tunity for  the  extravasated  blood  to  escape,  a  free  incision  should 
be  made  the  whole  length  of  the  tumour  with  a  scalpel,  or  the 
shoulder  of  a  lancet.  I  am  not  certain  whether  this  plan  has  ever 
been  insisted  on  by  any  writer,  when  the  tumour  preserves  its  in- 
tegrity ;  but  whether  or  not,  I  am  convinced  at  the  present  mo- 
ment it  is  the  best  mode  of  treatment. 

Several  advantages  present  themselves  from  making  the  inci- 
sion just  recommended:  first,  we  may  prevent  sloughing,  which 
is  always  desirable  when  these  parts  are  concerned ;  secondly,  the 
patient  is  quickly  relieved  from  the  excessive  pain  which  constantly 
attends  this  complaint;  thirdly,  the  extravasated  and  decomposing 
blood  has  a  better  opportunity  to  discharge  itself,  and  consequently 
the  progress  of  the  cure  hastened;  fourthly,  it  will  sooner  allow  of 
antiseptic  applications,  to  correct  the  extreme  fetor  of  the  putre- 
fying coagula. 

The  urine  must  be  relieved  as  soon  as  the  distention  of  the 
bladder  becomes  troublesome ;  this  may  generally  be  effected  by 
pressing  the  enlarged  labium  gently  to  one  side,  and  slightly  ele- 


38  BLOODY   INFILTRATIONS   IN 

vating  it — should  this  not  succeed,  the  catheter  must  be  introduced 
pro  re  nata. 

The  bowels  must  be  purged  by  any  of  the  neutral  salts ;  but 
the  patient  must  not  be  permitted  to  rise  during  their  operation  ; 
cloths  must  be  placed  under  her  to  receive  the  faeces,  as  well  as 
to  catch  the  urine,  when  she  is  about  to  pass  them.  If  she  be 
permitted  to  get  out  of  bed,  it  will  create  much  unnecessary 
pain,  besides  incurring  the  risk  of  the  renewal  of  the  bleeding,  by 
the  rude  and  too  sudden  separation  of  a  coagulum.  The  strictest 
antiphlogistic  regimen  should  be  observed.  We  are  told  of  cases, 
where  the  bleeding  has  been  considerable  after  the  part  has  given 
way;  to  arrest  which  the  wound  was  crammed  with  lint,  and 
the  vagina  itself  firmly  plugged.  I  have  never  seen  any  bleeding 
follow  the  plan  just  suggested  ;  nor  do  I  see  how  it  can  well  occur, 
without  attempts  have  been  made  too  early,  and  too  rudely,  to  sepa- 
rate, or  remove  the  impacted  coagula.  This  must  be  carefully 
avoided ;  and  their  separation  confined  strictly  to  the  powers  of 
the  system,  unless  it  be  the  portions  that  separate  themselves  in 
consequence  of  the  putrefaction  of  the  blood  itself,  or  by  very 
gentle  pressure.  The  detached  coagula  of  course  should  always 
be  removed,  as  often  as  they  may  separate. 

It  contributes  greatly  to  the  comfort  of  the  patient,  as  well  as 
being  important  to  the  cure,  to  keep  the  parts  as  clean  as  possi- 
ble by  frequent  washing — for  this  purpose  plain  soap  and  water 
is  as  useful  as  any  other  mere  detergent.  The  charcoal  poultice 
is  highly  important,  and  should  be  constantly  employed.  The 
best  mode  of  applying  the  poultice  is  to  spread  over  its  surface  a 
piece  of  gauze  or  very  thin  muslin,  that  the  charcoal  may  not 
adhere  to  the  wound.  Every  loose  portion  of  coagulum  should 
be  removed  at  each  dressing,  by  carefully  washing  the  part,  as 
just  directed;  and  the  poultice  should  be  changed  every  three  or 
four  hours,  at  farthest.  The  wound  may  be  washed  with  a  mix- 
ture of  the  pyroligneous  acid  and  water;  and  the  same  acid  may 
be  profitably  employed  in  its  concentrated  form  over  the  poultice, 
by  wetting  folded  linen  with  it. 

Before  the  wound  heals,  the  patient  generally  becomes  consi- 
derably weakened  from  the  excessive  discharge  of  pus,  &c.'  Her 
strength  should  be  supported  by  a  decoction  of  bark,  the  sulphate 
of  quinine,  elixir  of  vitriol,  and  a  more  generous  diet,  provided  no 
febrile  irritation  remain.  The  following  cases,  (all  I  have  witnessed,) 
will  illustrate  the  routine  of  practice. 

Case  I.— 1806,  April  24th.  I  was  called  by  Mrs.  Rose,  the 
elder,  to  Mrs.  G.,  who  was  in  labour  with  twins.  At  1  o'clock, 
P.  M.,  she  was  delivered  of  a  female  child.  About  ten  minutes 
after  its  birth,  the  right  labium  pudendi  became  excessively 
gwelled,  which  alarmed  the  midwife,  and  occasioned  my  being 
called.  The  part  was  found  upon  inspection  by  Mrs.  R.  to  be 


THE   LABIA  PUDENDI.  39 

distended  to  its  utmost  bearing;  extremely  black;  and  nothing 
but  the  internal  surface  of  the  labium  presented  itself.  Before  I 
arrived,  however,  the  tumour  had  burst,  from  the  efforts  made  to 
expel  the  second  child.  When  I  examined  the  patient,  there 
was  little  swelling  remaining  in  the  labium,  but  there  was  dis- 
covered a  considerable  opening  from  its  superior  portion  to  its  in- 
sertion in  the  perineum.  The  second  child  was  well  situated; 
pelvis  faulty ;  pains  pretty  frequent  and  severe ;  and  great  pain 
was  experienced  immediately  above  the  pubes.  In  about  fifteen 
minutes  after  my  seeing  the  patient,  the  labium  was  again  dis- 
tended, and  again  it  discharged  itself:  this  took  place  four  times 
before  the  birth  of  the  child.  This  frequent  bursting  destroyed 
the  connexion  of  the  labia  with  each  other  so  completely,  as  to 
leave  nothing  but  the  common  skin  at  the  perineum  to  support  the 
pressure  of  the  Child's  head  when  passing  through  the  external 
parts ;  this  proved  insufficient  to  sustain  the  force  with  which  it 
was  urged  against  it,  and  an  extensive  laceration,  even  to  the 
verge  of  the  anus,  took  place,  notwithstanding  every  precaution 
which  a  timely  fear  could  suggest.  She  lost  from  the  part,  by 
this  laceration,  at  least  twelve  ounces  of  blood. 

25th.  Complains  of  no  soreness  in  the  parts ;  the  swelling  nearly 
subsided;  is  feverish;  some  slight  after-pains;  passes  no  water; 
ordered  a  tea-spoonful  of  the  sweet  spirit  of  nitre,  and  a  purgative 
enema. 

26th.  She  passed  water  freely,  after  the  sweet  spirit  of  nitre  and 
the  enema.  From  this  time  but  little  inconvenience  was  expe- 
rienced, except  that  which  arose  from  the  lacerated  perineum. 
She  was  confined  for  some  time  to  a  horizontal  posture,  and  at  the 
end  of  the  month  was  pretty  well  recovered. 

This  case  differs  very  much  from  the  two  about  to  be  related, 
first,  in  the  blood  being  discharged  from  the  tumour  almost  as  soon 
as  formed ;  secondly,  in  the  integrity  of  the  perineum  being  very 
much  injured  by  the  repeated  yielding  of  the  labial  tumour,  and  in 
laceration  being  inevitable ;  thirdly,  in  the  wound  healing  up  in 
the  labia  without  trouble,  in  consequence  of  its  cellular  structure 
retaining  no  coagula. 

Case  II. — 1809,  July  2nd.  Mrs.  A.  was  delivered,  at  11 
o'clock,  A.  M.,  of  her  second  child,  which  was  very  large,  after 
a  severe  labour  of  four  hours.  She  appeared  very  well  after 
delivery,  except  the  frequent  recurrence  of  severe  after-pains, 
which,  however,  were  relieved  by  the  use  of  opium.  At  9  o'clock, 
P.  M.  she  complained  of  much  pain,  soreness,  and  tension,  in  the 
right  labium  pudendi,  which,  upon  examination,  was  found  to  be 
much  swelled ;  it  continued  to  increase  until  it  acquired  a  very 
large  size,  and  quickly  became  vesicated.  The  internal  lining  of 
the  labium  was  stretched  to  extreme  thinness;  wag  very  black; 
and  studded  all  over  with  little  blisters,  which  contained  a  yellowish 


40 

serum.  I  made  with  the  point  of  a  lancet  a  number  of  punctures, 
from  -which  issued  a  considerable  quantity  of  bloody  serum ;  this 
afforded  much  relief. 

3d.  Pain  rather  less ;  fever  and  delirium ;  no  discharge  of  urine, 
owing  to  the  pressure  of  the  tumour  upon  the  mouth  of  the  ure- 
thra. She  was  ordered  to  lose  twelve  ounces  of  blood — the  urine 
was  relieved  by  pressing  the  tumour  to  one  side,  and  at  the  same 
time  raising  it  a  little.  An  incision  was  made  with  the  shoulder 
of  a  lancet  through  the  extent  of  the  inner  portion  of  the  tumour; 
this  brought  into  view  the  coagula,  with  which  the  whole  of  the 
cellular  structure  of  the  part  was  completely  engorged  ;  mueh  re- 
lief followed  this  operation.  A  strict  antiphlogistic  regimen  was 
ordered. 

4th.  Pain  and  fever  much  diminished;  urine  relieved  as  yes- 
terday ;  a  considerable  discharge  of  thin,  grumous,  fetid  blood ; 
bowels  confined ;  an  ounce  of  the  sulphate  of  magnesia  was  given, 
and  the  charcoal  poultice  was  directed. 

5th.  Pain  less ;  urine  unobstructed.  The  salts  operated  well. 
The  discharge  from  wound  considerable,  but  extremely  fetid. 
Fever  diminished — poultice  continued. 

6th.  Freer  from  pain  and  fever ;  urine  free — fetor  of  the  dis- 
charge extreme.  Four  or  five  ounces  of  coagulum  dislodged  by 
gently  and  firmly  pressing  the  external  and  inferior  portion  of  the 
tumour.  Poultice  continued. 

7th.  Nearly  free  from  pain ;  fetor  of  discharge  diminished ;  the 
tumour  lessened  in  size.  More  of  the  coagulum  discharged  by 
the  same  means.  Fever  nearly  gone — urine  free ;  bowels  confined. 
Salts  repeated. 

8th.  No  pain — can  turn  on  either  side — fever  gone — fetor  less, 
though  the  discharge  is  considerable. 

15th.  The  coagulum  entirely  evacuated — healthy  pus;  fever 
none;  fetor  gone.  From  this  time  the  parts  healed  kindly,  and 
in  the  sixth  week  they  were  entirely  well.  Her  strength  much 
improved  by  the  bark  in  decoction,  and  the  elixir  vitriol.  I  attended 
this  lady  with  several  children  after  this  time,  without  the  smallest 
aceident  happening  to  the  parts. 

Case  III. — 1809,  August  30th.  Mrs.  C.  was  delivered  about 
5  o'clock,  P.  M.,  of  a  large  first  child,  after  a  labour  of  six  hours. 
The  midwife  left  her  about  an  hour  after,  as  well  as  is  common. 
At  10  o'clock  the  same  evening,  I  was  sent  for  in  great  haste,  in 
consequence  of  a  large  and  sudden  swelling  taking  place  soon 
after  the  midwife  had  taken  her  leave.  Upon  inspection,  the 
left  labium  was  found  much  distended,  very  livid,  and  extremely 
painful.  The  distention  or  tumour  not  so  great  as  in  the  pre- 
ceding case;  this,  however,  was  perhaps,  in  a  degree,  owing  to 
my  having  been  sent  for  immediately  after  the  part  was  observed 
to  swell,  and  its  farther  progress  interrupted  by  my  puncturing 


THE   LABIA   PUDENDI.  41 

the  tumour  in  several  places,  which  gave  opportunity  for  a  con- 
siderable quantity  of  the  thinner  part  of  the  blood  to  escape  from 
them,  which  afforded  some  relief;  or  at  least  prevented  farther 
distention.  The  part  was  ordered  to  be  covered  with  a  soft 
bread  and  milk  poultice,  and,  as  she  was  suffering  much  pain,  a 
full  dose  of  laudanum  was  directed. 

31st.  Still  in  great  pain ;  high  fever,  and  the  tumour  as  large 
as  it  was  the  preceding  evening,  and  vesicated  as  in  the  former 
case.  Directed  the  loss  of  blood;  made  an  incision  the  whole 
length  of  the  tumour,  which  afforded  much  relief.  The  charcoal 
poultice  was  ordered,  and  the  urine  relieved  as  in  the  former 
case.  Matters  remained  pretty  much  the  same  until  the 

5th  of  September.  On  my  visit  this  day,  I  was  enabled,  with- 
out much  force,  to  express  a  large  portion  of  coagulum,  and  did 
so  every  succeeding  day,  until  the  15th ;  considerable  quantities 
had  come  away  at  every  dressing ;  and  at  this  time,  (the  15th,) 
the  sore  was  entirely  free  from  it,  and  presented  a  large,  but  a 
healthy  surface.  The  charcoal  poultice  was  continued  until  the 
wound  suppurated ;  it  was  then,  as  well  as  in  the  other  case,  dressed 
with  simple  cerate.  The  wound  was  entirely  closed  by  the  end  of 
the  fifth  week.  Her  strength  was  improved  by  bark,  &c. 

In  neither  of  the  three  cases  just  related,  was  there  any  fungus 
produced,  to  interrupt  the  progress  of  the  cure ;  a  circumstance 
much  to  the  advantage  of  the  patient. 

The  mode  of  treatment  pursued  in  these  cases  appeared  to 
succeed  so  well,  that  I  have  been  induced  to  relate  it  pretty 
much  in  detail ;  and  I  have  been  more  strongly  induced  to  this, 
as  I  have  met  with  no  account  of  the  particular  mode  of  treating 
this  accident,  so  painful  and  alarming  to  the  patient,  and  embar- 
rassing to  the  young  practitioner.  The  incision  through  the  ex- 
tent of  the  tumour,  I  am  induced  to  believe  to  be  the  best  mode 
of  treating  it ;  for  we  can  never  expect  the  extravasated  blood  to 
be  absorbed;  and  when  the  distention  of  the  parts  is  not  very 
quickly  taken  off,  the  whole  of  the  internal  membrane  of  the  la- 
bium  will  be  sure  to  slough.  I  have,  therefore,  been  led  to  be- 
lieve it  to  be  the  better  practice,  though  I  have  no  authority  for 
it.  It  is  true  that  Le  Dran  mentions  his  having  evacuated  twenty 
ounces  of  blood  by  an  incision ;  but  the  plan  does  not  appear  to 
have  been  adopted  as  a  general  practice.  But,  from  the  relief  it 
afforded  in  the  two  cases  in  which  I  employed  it,  and  the  oppor- 
tunity it  immediately  gives  to  the  confined  coagulated  blood  to 
escape,  and  also  from  its  enabling  us  more  effectually  to  remove 
the  fetor,  lam  every  way  convinced  it  is  the  proper  mode  of  treat- 
ing these  tumours. 

I  have  ventured  to  recommend  the  use  of  the  pyroligneous 
acid,  from  analogy,  rather  than  from  experience,  in  this  particu- 
lar complaint.  But  its  efficacy  in  removing  the  stench  of  putre- 


42  IMPERFORATION,    ETC. 

faction,  even  that  of  cancer,  I  have  repeatedly  witnessed  ;  and  I 
recommend  it  for  the  complaint  in  question,  with  as  much  con- 
fidence as  can  arise  where  it  has  not  been  absolutely  tested. 

SECT.  VIII. — Imperforation,  and  too  great  Density  of  the  Hymen. 

A  dispute  has  long  been  maintained,  by  a  number  of  celebrated 
anatomists,  whether  there  really  belongs  to  the  female  organs  of 
generation,  the  appendage  called  hymen.  The  dispute  is  far 
from  being  settled  to  this  day :  nor  is  it  a  matter  of  much  conse- 
quence whether  it  ever  be,  or  even  whether  it  ever  can  be,  if  the 
same  mode  of  reasoning  be  followed  by  all  who  deny  its  existence. 
If  it  be  attempted  to  demonstrate  its  presence,  they,  like  Ambrose 
Par6,  declare  it  to  be  an  unnatural  production.  For  if  the  occa- 
sional absence  of  a  production  is  to  be  assumed  as  the  natural 
condition,  in  defiance  of  its  frequent  presence,  it  would  "  confound 
all  our  philosophy  ;"  for  acephali  would  be  considered  as  the  na- 
tural state  of  the  human  body,  in  spite  of  the  ten  thousand  exam- 
pies  to  the  contrary. 

All  that  has  been  urged  by  Fallopius,  Vesalius,  De  Graaf,  Buf- 
fon  and  many  others,  amounts  but  to  this  negative ;  that  they  did 
not  always  find  the  hymen  when  they  sought  for  it.  And  the 
cause  of  this  is,  perhaps,  satisfactorily  accounted  for  by  Cuvier, 
by  saying,  "  Pendant  longtemps  il  y  a  eu  des  disputes  assez  ridi- 
cules sur  1'existance,  de  cette  membrane;  on  avait  peu  d'occa- 
sions  de  la  voir,  £  une  6poque  od  1'anatomie  ne  s'exergait  que  sur 
les  cadavres  criminels,  et  Ton  s'appuya  ensuite  sur  des  observa- 
tions incomplettes,  pour  soutenir  des  systemes  hazardes." — Diet, 
des  Scien.  Med.,  art.  Hymen. 

If  the  existence  of  the  hymen  be  denied,  it  would  be  in  vain  to 
talk  of  its  imperforate  state  ;  yet  those  who  have  done  so  have 
furnished  examples  of  this  condition.  With  respect  to  this  state 
of  the  hymen,  we  have  nothing  to  add  from  our  own  experience, 
as  we  have  never  met  with  an  instance  of  impevforation.  All, 
therefore,  that  we  can  say  upon  this  subject,  must  be  derived 
from  the  observations  of  others. 

The  first  inconvenience  that  is  experienced,  is  soon  after  pu- 
berty :  the  menstruous  fluid  is  duly  secreted ;  but,  not  finding  an 
outlet,  it  accumulates  from  time  to  time,  until  the  uterus  itself, 
after  the  vagina  is  completely  filled,  becomes  distended,  and  this 
sometimes  to  a  very  large  size,  before  the  cause  of  suffering  is 
discovered.  Thus,  Dr.  Denman  relates  an  interesting  history, 
where  this  state  existed  in  a  young  lady,  who,  after  incurring  the 
ill-natured  suspicions  of  those  around  her,  submitted  to  an  exami- 
nation, which  eventuated  in  the  discovery  of  the  imperforate  state 
of  the  hymen.  The  Doctor  says,  "  The  circumscribed  tumour  of 


OF    THE    HYMEX.  43 

the  uterus  was  found  to  reach  as  high  as  the  navel,  and  the 
external  parts  were  stretched  by  a  round  soft  substance  at  the 
entrance  of  the  vagina,  in  such  a  manner,  as  to  resemble  that 
appearance  which  they  have  when  the  head  of  a  child  is  passing 
through  them;  but  there  was  no  entrance  into  the  vagina.  On 
the  following  morning  an  incision  was  carefully  made  through  the 
hymen,  which  had  a  fleshy  appearance,  and  was  thickened  in  pro- 
portion to  its  distention.  Not  less  than  four  pounds  of  blood,  of 
the  colour  and  consistence  of  tar,  were  discharged;1  and  the  tume- 
faction of  the  abdomen  was  immediately  removed.  Several  stellated 
incisions  were  afterwards  made  through  the  divided  edges,  which  is 
a  very  necessary  part  of  the  operation;  and  care  was  taken  to  pre- 
vent a  reunion  of  the  hymen  till  the  next  period  of  menstruation, 
after  which  she  suffered  no  inconvenience." — Introduction  to  Mid. 
Francis's  ed.  p.  110. 

When  the  hymen  is  imperforate,  the  patient  suffers  at  each  re- 
turn of  the  menstrual  period;  and  these  pains  so  much  resemble 
the  pains  of  labour,  as  to  have  been  sometimes  mistaken  for  them. 
Dr.  M'Cauly  confesses,  that,  in  one  instance,  he  mistook  the  pro- 
trusion of  the  hymen  for  the  membranes  forced  down  by  the  pains 
of  labour;  this  case,  like  that  of  Dr.  Denman,  was  relieved  by  in- 
cision through  the  dense  and  resisting  membrane.  Smellie's  Col. 
I.  No.  1,  Case  V. 

In  the  case  just  related  from  Sraellie,  the  patient  suffered  se- 
verely; and  what  added  to  her  distress  much  was  the  suppres- 
sion of  urine,  which  was  not  relieved  until  the  contents  of  the 
vagina  were  discharged.2  There  is  something  curious  in  the 
economy  of  the  uterus,  when  its  body  becomes  distended  by  the 
accumulation  of  the  menstruous  fluid:  it  seems  to  yield  for  a  time 
without  much  opposition;  but  by  and  by  it  makes  an  effort  to 
discharge  its  contents,  and  pains  are  excited.  After  these  pains 

1  Dr.  Denman  observes  of  this  blood,  that,  "it  was  not  putrid,  nor  coagulated, 
and  seemed  to  have  undergone  no  other  change,  after  its  secretion,  but  what  was 
occasioned  by  the  absorption  of  its  more  fluid  parts."  This  is  one  among  the  many 
proofs  that  present  themselves,  that  the  menstruous  fluid  is  not  common  blooii. 
Frank  mentions  a  case,  (torn.  3,  p.  243,)  from  "  Les  Actes  Medico-Physiques,"  of  a 
young  girl  of  fifteen  years  of  age,  in  which  the  hymen  was  imperforate.  Her  ab'lo- 
men  was  distended  as  much  as  is  usual  at  the  sixth  month  of  pregnancy,  from  the 
accumulated  blood  behind  the  obstacle.  She  was  subject  to  violent  pains  in  the 
back,  hypogastrium,  and  in  the  genitals;  and  thought  she  felt  something  within  her. 
An  incision  was  made  through  the  hymen,  from  which  were  discharged  five  pounds 
of  thick  black  blood,  without  any  disagreeable  odour,  and  by  which  she  was  entirely 
relieved.  He  also  mentions  one,  furnished  by  one  of  his  pupils,  of  a  young  girl,  whom 
every  body  accused  of  being  pregnant — an  incision  through  the  hymen  gave  issue  to 
several  pints  of  blood,  no  ways  changed;  this  operation  was  followed  by  fainting,  but 
the  girl's  reputation  was  saved. 

3  A  similar  case  is  reported  by  Mr.  Coley,  in  the  "  Provincial  Medical  and  Surgical 
Transactions."  In  this  case,  recourse  was  had  to  the  division  of  the  hymen  with 
entire  success.  "  Nearly  four  pints  of  tar-like  fluid  gushed  out." — See  Medico- 
Chirurg.  Rev.  for  July,  1833,  p.  190. 


44 

have  continued  awhile,  they  cease;  nor  are  they  renewed,  until 
another  menstrual  period  arrives.  It  is  now  again  stimulated  to 
contraction,  and  pains  again  declare  themselves ;  and  in  this 
manner,  things  proceed  until  art  affords  relief.  The  most  re- 
markable circumstance  attending  these  cases  is  the  cessation 
and  renewal  of  pain.  The  menstruous  fluid  is,  to  all  intents  and 
purposes,  an  extraneous  substance  to  the  cavity  of  the  uterus 
when  retained  there ;  the  surprise  is,  that  it  should  not  continue 
its  painful  contractions  without  ceasing,  but  this  is  not  the  case 
— for  after  continuing  a  certain  time,  the  patient  enjoys  an  interval 
of  ease ;  nor  is  the  calm  disturbed,  until  a  fresh  secretion,  by  re- 
newing distention,  again  provokes  it  to  contraction.  This  calm 
may  be,  and  most  probably  is,  owing  to  the  thinner  parts  of  this 
fluid  being  absorbed. 

In  consequence  of  the  vagina  and  uterus  being  filled  with  this 
fluid,  its  pressure  after  awhile  becomes  very  severe;  it  not  only 
produces  pain,  as  just  stated,  but  it  also  interrupts  two  important 
functions;  namely,  the  discharge  of  urine,  and  the  evacuation  of 
the  faeces.  And  in  a  case  related  by  Mr.  Fynney,1  convulsions 
were  repeatedly  produced.  Mr.  Fynney,  in  his  case,  had  to  con- 
tend with  a  hymen  "more  than  an  inch  thick;"  this  is  not,  how- 
ever, usual,  agreeably  to  Mr.  Burns,  who  declares  they  are  gene- 
rally thin.  The  quantity  of  fluid  discharged  is  sometimes  very 
large.  In  most  of  the  cases  it  is  said  to  be  at  least  two  quarts ; 
but  Benevoli,  as  quoted  by  Mr.  Burns,  makes  the  quantity  in  his 
patient  to  be  thirty-two  pints.  They  appear  all  to  agree  as  to  the 
appearance  of  the  evacuated  fluid — for  in  no  instance  is  it  men- 
tioned, that  it  is  found  coagulated. 

The  remedy,  in  all  instances,  appears  to  be  the  same :  it  is  to 
cut  through  the  confining  membrane.  In  some  instances,  as  just 
noticed,  the  hymen  has  been  found  very  thick ;  which,  of  course, 
will  require  additional  caution  in  the  performance  of  the  opera- 
tion. It  is  desirable,  upon  such  occasions,  that  the  parts  be  well 
distended,  as  it  not  only  gives  greater  facility  to  the  operation, 
but  also  additional  safety.  Dr.  Denman  says,  "  Some  caution  is 
required  when  the  hymen  is  closed,  in  those  who  are  advanced  in, 
life,  unless  the  membrane  be  distended  by  the  confined  menses, 
as  I  once  saw  an  instance  of  inflammation  of  the  peritoneum, 
being  immediately  produced  by  the  operation,  of  which  the  pa- 
tient died,  as  in  the  true  puerperal  fever,  and  no  other  reason 
could  be  assigned  for  the  disease."  Introd.  p.  110.  And,  in 
confirmation  of  this  opinion,  we  will  mention  a  case  of  imper- 
forate  hymen,  in  which  the  operation  was  performed,  and  was 
followed  by  death.  In  a  report  of  the  "  Lowestoft  Infirmary," 
there  is  a  case  recorded  by  Mr.  W.  C.  Worth ington,  of  a  girl  of 

'  Med.  Comment.  Vol.  III.  p.  194. 


OF    THE    HYMEN.  45 

fourteen  years  old,  on  whom  was  performed  the  operation  for  the 
retained  menses,  by  cutting  through  "a  dense  cellular  structure, 
of  half  an  inch  in  thickness,  situated  at  the  orifice  of  the  vagina," 
and  through  which  was  discharged  "  about  a  pound  of  dark- 
coloured  fluid."  "The  third  day  after  the  operation,  severe  pain 
in  the  abdomen,  with  extreme  tenderness,  supervened,  together 
with  exquisite  gastric  irritation.  Notwithstanding  a  strict  anti- 
phlogistic plan  of  treatment  was  adopted,  the  patient  died  on  the 
following  morning." 

On  examination,  it  was  evident,  that  exquisite  peritonitis  was 
the  cause  of  death,  as  just  mentioned  by  Dr.  Denman.  Mr. 
Worthington  or  the  editor  of  the  Med.  Chir.  Rev.,  relates  a  case 
from  Professor  Langenbec,  very  analogous  to  this:  the  patient 
died  on  the  fifth  day,  and,  in  consequence  of  which,  he  gives 
precisely  the  opposite  opinion  of  Dr.  D.,  namely,  that  the  opera- 
tion should  be  performed  early,  and  before  the  accumulation  is 
great.  In  considering  these  cases,  we  should  be  inclined  to  the 
opinion  of  Dr.  D.,  and  for  the  reason  he  urges.  In  the  case  above 
related  by  Mr.  "VV.,  it  is  evident  that  the  parts  were  but  very 
moderately  distended,  as  but  "about  a  pound  of  fluid"  was  eva- 
cuated. In  the  fatal  cases  related,  it  is  more  than  probable  that 
a  portion  of  the  vagina  was  cut  through,  and  the  peritoneum  thus 
wounded;  now  if  this  be  true,  it  is  evident,  that  the  more  the 
parts  are  distended,  the  less  will  be  the  risk  of  this  accident. 

The  hymen  is  sometimes  found  extremely  dense,  though  per- 
forated sufficiently  for  the  passage  of  the  menses,  but  not  enough 
to  admit  with  freedom  the  venereal  congress.  Yet  it  seems  it 
does  not  prevent  conception,  however  it  may  embarrass  coition. 
A  number  of  unquestionable  cases  are  upon  record,  where  this 
act  was  never  properly  consummated;  yet  the  women  were  im- 
pregnated, and  the  child's  passage  through  the  os  externum  was 
facilitated  by  an  operation  at  the  last  period  of  labour.  Hildanus, 
Pare,  Ruysch,  Mauriceau,  and  many  others,  make  mention  of  such 
cases. 

The  late  Dr.  Cleaver  invited  my  friend  Dr.  Chapman  and 
myself  to  witness  a  case  of  this  kind.  The  woman  had  been  in 
labour  with  a  first  child,  for  at  least  twelve  hours,  when  we  saw 
her;  the  pains  were  now  strong  and  frequent;  the  perineum  very 
much  distended,  and  alone  supported  the  efforts  of  the  uterus. 
The  os  externum  was  entirely  closed,  if  we  except  an  opening  of 
about  the  size  of  a  common  goose-quill.  Things  had  been  pre- 
cisely in  this  situation,  several  hours  before  we  were  called;  and 
as  all  chance  of  spontaneous  dilatation,  or  even  one  effected  by 
the  force  of  pain,  was  at  an  end,  it  was  thought  best  to  cut  the 
rigid  hymen,  and  give  a  chance  to  the  vagina  to  dilate,  and  the 
perineum  to  unfold. 

I   accordingly  passed   a   probe-pointed   bistoury  between   the 


46  PRURITUS. 

child's  head  and  the  hymen,  and  made  a  slight  incision  in  the 
latter,  which  enabled  me  to  introduce  a  finger,  by  which  I  di- 
lated, or  rather  broke  down,  the  whole  of  the  resisting  mem- 
brane, in  such  a  manner,  that  there  was  nothing  but  the  natural 
resistance  of  the  parts  to  contend  with.  In  about  two  hours  more 
the  child  was  safely  delivered,  and  without  the  parts  sustaining 
any  injury  by  the  passing  of  the  head. 

The  mode  of  operating  in  this  case  perhaps  may  not  have  been 
different  from  that  pursued  by  others  under  similar  circumstances ; 
for  none,  so  far  as  I  know,  have  described  the  exact  manner  in 
which  it  was  performed.  But,  as  they  have  been  silent  upon  this 
point,  and  as  my  previous  impressions  as  to  the  mode  of  affording 
relief,  were  altogether  different  from  what  I  found  necessary  in 
this  case,  I  think  it  best,  it  should  be  clearly  understood,  that  all 
that  can  be  necessary  to  ensure  success  to  the  operation  is,  merely 
to  destroy  the  continuity  of  the  hymen  in  one  part  of  it;  for  by 
this  means  the  opening  will  be  large  enough  immediately  for  the 
finger  to  pass ;  and  by  the  aid  of  which,  by  giving  it  a  rotatory 
motion,  the  adhesions  of  the  hymen  with  the  vagina  may  certainly 
be  destroyed — at  least,  so  it  appears  from  its  success  in  this  case. 
I  cannot  think  it  ever  necessary,  on  reflecting  upon  the  mechanism 
of  these  parts,  to  cut  into  either  the  vagina  or  perineum,  or  even 
to  wound  them. 


SECT.  IX. — Of  Pruritus,  or  the  Aphthous  Condition  of  the  Vulva 

and  Vagina. 

One  of  the  most  troublesome  and  distressing  complaints  to 
which  the  female  is  subject,  is  the  pruritus,  or  itching  of  the  pu- 
dendum. Women  who  are  not  pregnant  are  subject  to  this  com- 
plaint; though  not  equally  liable  as  those  who  are;  in  both,  the 
desire  to  scratch  is  so  indomitable,  as  sometimes  to  put  decency 
at  defiance.  I  knew  one  instance  in  which  the  itching  was  so 
severe,  and  so  continued,  that  the  lady  was  obliged  to  keep  her 
chamber  for  three  months.  The  only  relief  that  was  found  in 
this  case,  was  from  the  almost  constant  application  of  water,  in 
which,  ice  was  dissolved.  Every  remedy  that  could  be  suggested 
by  two  eminent  practitioners  of  this  city,  was  tried  in  vain.  No 
relief  was  obtained  until  after  delivery.  This  case  came  to  my 
knowledge  in  the  year  1796,  by  being  related  by  one  of  the  gentle- 
men in  attendance.  The  parts  were  not  examined;  the  child 
was  delivered  perfectly  healthy,  though  the  mother  was  much  ex- 
hausted by  her  long  sufferings,  and  the  severe  discipline  to  which 
she  submitted  in  hope  of  relief. 

The  disease  may  attack  the  whole  of  the  vulva,  and  sometimes 
it  affects  the  vagina.  .It  sometimes  commences  in  the  early  part 


PRURITUS.  47 

of  pregnancy :  when  this  happens,  and  is  neglected,  it  may  con- 
tinue until  delivery  takes  place.  At  other  times,  and  this  I  be- 
lieve to  be  the  most  common,  it  does  not  attack  until  the  sixth  or 
seventh  month.  If  cleanliness  be  not  observed,  the  complaint  is 
sure  to  be  much  aggravated;  though  no  attention  of  this  kind  of 
itself  is  capable  of  preventing  or  overcoming  this  complaint. 

A  great  variety  of  causes  have  been  assigned  for  this  disease ; 
such  as  want  of  cleanliness ;  an  acrid  secretion  within  the  labia ;  an 
inveterate  eruption ;  the  pediculi  pubis ;  varicose  veins ;  an  aphthous 
efflorescence,  &c. 

It  is  certain  that  in  a  number  of  the  cases  which  have  fallen 
under  my  notice,  a  want  of  cleanliness  could  not  be  considered 
as  a  cause;  though  we  are  persuaded  it  is  well  calculated  to  in- 
crease it.  There  must  be  a  secretion  of  some  acrid  fluid  in  all 
cases  of  pruritus,  be  the  remote  cause  what  it  may ;  and  it  seems 
to  renew  the  itching  whenever  it  may  happen.  In  some  instances, 
this  itching  has  intervals  of  longer  or  shorter  duration;  and  its 
return  seems  to  be  produced  by  a  discharge  taking  place  of  a 
thin  and  generally  limpid  serum,  of  which  the  woman  is  perfectly 
conscious;  and  aware,  at  the  same  moment,  that  her  troubles  are 
about  to  be  renewed.  I  have  met  with  no  instance  in  which  a 
dartrous  eruption,  or  pediculi  pubis,  could  be  considered  as 
causes;  nor  have  I  met  with  one  where  it  has  arisen  from  a  va- 
ricose vein. 

The  aphthous  efflorescence,  as  an  attendant  on  this  complaint, 
we  believe  we  were  the  first  to  point  out ;  and  for  this  discovery 
we  were  indebted  to  accident,  as  will  be  now  mentioned. 

The  precise  nature  of  this  affection  had  not  been  pointed  out ; 
and  accident  furnished  me  with  an  opportunity  of  detecting  a  con- 
dition of  the  parts,  where  this  complaint  was  in  full  force,  which 
has  never,  I  believe,  been  noticed  by  any  one ;  and  which  led  to, 
generally,  a  very  successful  mode  of  practice. 

A  lady,  whose  husband  was  more  notorious  for  his  gallantries 
than  for  his  domestic  virtues,  was  attacked,  in  the  incipient  stage 
of  pregnancy,  with  an  intolerable  itching  in  the  pudendum,  and 
even  within  the  os  externum.  The  woman  suspecting  the  affec- 
tion to  be  venereal,  I  was  sent  for  in  April,  1815,  and  she  gave 
such  an  account  of  her  feelings  as  to  make  me  think  it  might  truly 
be  the  case;  I  therefore  proposed  an  examination  of  the  parts; 
which  was  finally  acceded  to.  Upon  separating  the  labia,  the 
whole  face  of  the  vulva,  the  os  externum,  and  as  much  of  the  vagina 
as  could  be  viewed,  were  covered  with  an  incrustation  of  aphthae. 
I  assured  the  patient  her  disease  was  not  what  she  suspected,  but 
one,  I  hoped,  that  could  be  quickly  removed.  I  accordingly  or- 
dered a  strong  solution  of  borax  in  water,  and  requested  her  to  wash 
the  parts  with  it  four  or  five  times  a  day;  as  well  as  to  throw  it  up 


48  PRURITUS. 

thfc  vagina  by  means  of  a  syringe.  She  did  so ;  and  was  perfectly 
•well  in  twenty-four  hours. 

I  was  led  to  the  employment  of  the  borax  in  this  case,  from 
the  analogy  which  the  thrush  in  children  furnished;  and  its  suc- 
cess since  has  led  me  to  regard  it,  if  not  as  a  certain,  yet  as  a 
very  valuable  remedy:  it  has  rarely  failed  in  my  hands,  or  in  the 
hands  of  others,  as  far  as  I  have  hitherto  learned.  It  therefore 
always  deserves  a  trial ;  especially  as  I  have  never  known  it  ag- 
gravate the  complaint.  I  have  had  a  number  of  cases  within  the 
last  few  years,  in  nearly  all  of  which  it  proved  completely  suc- 
cessful ;  but  not  with  equal  speed.  Two  of  these  cases  just  men- 
tioned were  pretty  obstinate,  but  especially  one;  in  both,  I  was 
obliged  to  bleed  and  purge  liberally;  and  to  confine  the  patients 
to  low  diet ;  but  in  one,  I  was  under  the  necessity  of  applying 
leeches  to  the  part,  before  the  disease  would  yield.  I  thought 
that  small  doses  of  magnesia,  with  the  daily  use  of  lime  water  and 
milk,  were  useful  in  this  case.  But,  in  the  others,  the  disease 
yielded,  almost  immediately,  to  the  simple  application  of  the  borax 
and  water. 

Where  this  complaint  proves  at  all  obstinate,  depletion  adds 
very  much  to  the  influence  of  the  borax ;  I  therefore  would  ad- 
vise attention  to  this  circumstance.  I  am  now  certain,  however, 
that  in  every  case  of  pruritus,  there  does  not  exist  this  aphthous 
efflorescence.  I  have  had  but  three  opportunities  of  examining 
the  parts  under  such  circumstances ;  in  two  of  which  the  aphthous 
condition  obtained;  but  in  the  other  the  parts  were  as  described 
below.1 

We  do  not  know  in  what  proportion  of  cases  this  state  of  the 
parts  may  exist — we  are  well  satisfied,  it  is  not  present  in  all. 
This  fact  we  were  enabled  to  ascertain  a  few  years  since :  in  this 
case,  the  external  labia,  the  whole  vestibulum,  the  carunculse 
myrtiformes,  and  as  much  of  the  vagina  as  could  well  be  viewed, 

'  Cases  certainly  do  occur  in  practice,  that  have  not  yielded  to  the  plan  we 
have  suggested ;  therefore  we  feel  grateful  for  the  knowledge  of  any  remedy  that 
has  proved  successful,  when  the  ordinary  means  have  proved  otherwise.  We  there- 
fore, feel  indebted  to  Dr.  Philip  Younge,  of  Thoroaston,  Georgia,  for  the  following 
case,  in  which  dry  calomel  proved  highly  useful.  "  I  had  it  sprinkled,"  says  the 
Doctor,  "over  every  spot  of  inflammation  within  the  v\ilva,  as  thoroughly  as  the  na- 
ture of  things  would  permit,  three  or  four  times  a  day.  Whenever  the  itching  be- 
rame  urgent,  my  advice  was  to  wash  the  part,  by  means  of  a  syringe,  with  cold 
water,  and  reapply  the  dry  calomel,  which  immediately  calms  the  most  insufferable 
irritation.  I  have  pursued  this  plan,  when  the  disease  appeared  perfectly  unma- 
nageable, with  the  happiest  effects;  although  the  disposition  to  recur  was  manifest 
until  delivery,  this  remedy  always  appeased  the  distress."  Amer.  Journ.  of  Med. 
Sci.  for  Aug.  1833,  p.  555. 

Dr.  Carron  du  Villards,  says  he  has  employed,  with  much  advantage,  lotions  of 
the  distilled  water  of  the  Prunus  lauro-cerasus,  in  this  complaint,  after  it  had  resisted 
every  other  application. — Id.  for  Nov.  1834. 


PRURITUS.  49 

were  swelled  and  much  inflamed.  The  appearance  of  the  in- 
flammation was  singular;  it  was  of  a  copper  red-colour,  with  a 
number  of  slight  abrasions ;  by  which  the  sensibility  of  the  parts 
was  very  much  increased.  From  the  whole  of  the  inflamed  sur- 
face, an  ichorous  dew  seemed  to  be  distilling  constantly;  and  when 
this  accumulated  in  a  sufficient  quantity  to  make  the  woman  sen- 
sible a  discharge  was  taking  place,  a  most  intolerable  itching  would 
begin ;  nor  would  it  cease,  until  the  poor  woman  would  be  almost 
exhausted  by  her  efforts  to  appease  it.  Cold  iced  water  was  her 
only  solace ;  and  this  afforded  but  a  very  temporary  suspension  of 
her  misery. 

This  patient,  it  may  be  proper  to  remark,  was  not  pregnant ;  she 
was  advancing  toward  the  critical  period  of  life,  and  had  been  al- 
ways, at  least  for  many  years,  subject  to  fluor  albus.  Suspecting 
some  disease  in  the  uterus  itself,  I  examined  my  patient  per  va- 
ginam :  this  afforded  no  room  to  suspect  any  thing  wrong  with  this 
organ ;  I  also  carefully  traced  the  urethra,  but  could  detect  nothing 
amiss  in  it.  I  prescribed  a  free  use  of  the  saturated  solution  of 
the  borax,  both  as  a  wash,  and  as  an  injection :  from  this,  much 
relief  was  experienced;  but  the  disease  not  yielding,  as  I  had  fre- 
quently found  it  do  in  other  cases,  I  began  the  use  of  the  balsam 
copaiva,  agreeably  to  a  suggestion  of  my  friend,  Dr.  Ruan,  of  its 
usefulness  in  this  complaint:  in  this  she  persevered,  and  in  a  few 
days  she  was  completely  relieved. 

I  believe  the  balsam,  in  this  case,  contributed  much  to  the  relief 
of  the  poor  woman ;  this  belief  is  founded  on  its  success  in  another 
instance,  where '  it  alene  was  used,  if  we  except  frequent  bathing 
with  lukewarm  water,  one  bleeding,  brisk  purging,  and  an  extremely 
abstemious  diet. 

Dr.  Ruan  informs  me  he  has  succeeded  with  copaiva,  after  the 
borax  had  failed  in  several  instances ;  and,  so  far,  I  am  disposed 
to  consider  it  a  valuable  aid  to  this  article.  In  cases  of  pruritus 
accompanied  by  the  aphthous  incrustation,  I  think  the  borax  will 
almost  always  succeed ;  therefore,  I  prescribe  it  in  all  instances  for 
which  my  advice  is  required ;  but  what  proportion  these  cases  bear 
to  those  without  this  efflorescence,  I  am  altogether  unprepared  to 
say  at  this  moment. 

In  a  case  of  great  violence,  and  as  great  obstinacy,  where  it 
did  not  yield  to  depletion,  to  low  diet,  nor  the  borax,  instant  relief 
was  obtained  by  an  injection  of  a  small  teaspoonful  of  the  aqua 
ammonia  purae,  to  a  half  pint  of  water.  The  mixture  was  had 
recourse  to  in  the  middle  of  the  night  by  the  patient,  while  under 
great  agony  from  the  violence  and  pertinacity  of  the  itching;  and 
which  she  considered  rather  as  a  desperate  experiment,  than  as  a 
probable  means  of  relief;  yet  it  succeeded  like  a  charm.  During 
the  time  the  itching  was  troublesome  it  was  used  for  several 
days,  with  almost  instant  advantage ;  but  after  this,  it  seemed  to 
4 


f  ' 


50  PRURITUS. 

lose  its  influence.  The  borax  was  again  resorted  to ;  and  it  com- 
pletely succeeded ;  this  lady  was  three  months  advanced  in  preg- 
nancy, and  had  been  before  obnoxious  to  this  complaint,  when  in 
this  situation.  And  I  have  much  pleasure  in  stating,  since  this 
period,  I  have  found  much  benefit  derived  from  the  use  of  the  am- 
inoniated  water  as  just  directed,  in  several  very  troublesome  cases 
of  pruritus.1 

The  cases  which  occur  during  pregnancy  seem  more  obstinate 
than  those  which  take  place  at  other  times,  if  we  except  such  as 
occur  towards  the  decline  of  the  menses,  and  where  there  is  evi- 
dently a  disease  of  the  womb.  In  these  latter  cases  relief  may 
be  obtained;  but  they  are  perhaps  never  cured,  unless  the  affec- 
tion, of  which  pruritus  is  a  symptom,  is  also  removed.  Much 
will  depend  upon  frequent  washing,  and  often  rinsing  out  the  va- 
gina by  means  of  a  large  and  powerful  syringe.  The  solution  of 
borax  may  be  used  for  this  purpose  with  advantage ;  and  the  bal- 
sam copaiva  might  perhaps  be  useful  in  such  cases :  but  of  this, 
I  have  no  experience.  Opium,  or  opium  and  camphor,  at  bedtime, 
in  pretty  full  doses,  have  a  temporary  good  effect;  at  least,  it  pro- 
cures a  degree  of  rest  that  would  otherwise  be  denied.  The  woman 
should  exercise  much  forbearance,  and  not  too  easily  yield  to  the 
gratification  of  the  predominant  feeling.  I  have  had  a  case  lately, 
in  which  this  complaint  followed  abortion — it  was  immediately  re- 
lieved by  the  borax. 

This  complaint  has  been  generally  confounded  with  one  of  a 
very  different  character,  named  the  furor  uterinus,  but  they  are 
very  easily  distinguished  from  each  other ;  the  latter  is  a  volup- 
tuous sensation,  accompanied  by  venereal  desire ;  and  is  not  ac- 
companied by  an  itching,  properly  so  called;  but  by  a  sensual 
irritation,  which  makes  the  rubbing  of  the  parts  contribute  in  a 
degree  to  gratification.  The  pruritus,  on  the  other  hand,  is  an 

1  In  the  treatment  of  this  disease  it  is  of  much  consequence  that  the  local  re- 
medies should  be  thrown  up  the  vagina  by  a  syringe,  as  the  following  history  will 
show.  Mrs.  K.,  in  her  sixth  month  of  pregnancy,  was  attacked  with  pruritus. 
The  solution  of  borax  was  recommended.  On  calling  on  her  a  few  days  after,  she 
informed  me  she  was  not  relieved  in  the  slightest  degree.  I  inquired  whether  she 
was  careful  in  the  use  of  the  injection;  she  seemed  surprised  at  th'e  question.  I 
now  learned  that  her  husband  had  omitted  this  part  of  the  directions,  as  he  under- 
stood that  bathing  the  parts  was  all  that  was  necessary.  The  syringe  was  now 
made  use  of,  and  that  patient  was  entirely  and  promptly  relieved.  From  this  it 
would  appear,  that  the  efflorescence  may  occupy  the  vagina  to  a  considerable  ex- 
tent. 

Mr.  Churchill  seems  to  think  that  libidinous  desires  almost  always  attend  this 
complaint  when  it  exists  in  its  more  exquisite  form.  I  cannot  but  differ  from  him 
on  this  point.  Indeed  I  have  never  seen  nymphomania  result  as  a  "  degeneration  "* 
of  pruritus  vulvae.  The  former  is  decidedly  a  very  rare  disease  in  this  country.  I 
have  never  seen  more  than  two  or  three  well  marked  cases  of  it  in  the  whole  course 
of  my  practice. 

*  Princ.  Dis.  of  Females,  p.  7. 


PRURITUS.  51 

intense,  and  an  indomitable  itching,  not  accompanied  by  volup- 
tuous desire;  but  which  finds,  to  a  certain  extent,  a  relief  from 
scratching.1  For,  were  the  feelings  excited  in  these  cases  to  be 
allayed  by  any  mechanical  application,  one  would  be  selected 
that  would  better  comport  with  the  pruriency  of  the  thoughts 
which  suggested  the  necessity,  and  the  nature  of  the  means; 
while  the  other  would  seek  relief  from  the  application  of  the  nails, 
or  some  other  equally  rough  substance.  The  two  complaints 
must  therefore  be  looked  upon  as  altogether  distinct  in  their  na- 
ture and  objects;  nor  does  the  one  ever  degenerate  into  the  other, 
as  some  have  imagined;  for  there  is  no  analogy  whatever  be- 
tween pruritus  and  furor  uterinus.  For  the  one,  as  we  have 
said,  is  an  ungovernable  lasciviousness ;  the  other  an  intolerable 
itching,  without  the  slightest  desire.  Indeed,  from  all  I  can  learn 
on  this  subject,  pruritus  is  so  far  from  being  accompanied  by  de- 
sire, that  women  at  such  times  manifest  the  greatest  repugnance 
to  the  venereal  act. 

We  have  known  a  complaint  communicated  to  the  male,  by 
intercourse  with  a  woman  labouring  under  pruritus ;  it  was  very 
similar  to  that  which  infested  the  female,  in  its  general  charac- 
ter ;  that  is,  there  was  great  itching  and  swelling  of  the  prepuce ; 
the  whole  internal  surface  of  which,  together  with  the  glans  penis, 
were  covered  with  an  aphthous  efflorescence.  When  this  occurs 
with  the  married  man,  much  disturbance  is  sometimes  created, 
from  a  supposition  that  the  wife  has  been  unfaithful,  and  the  con- 
trary; and  much  will  depend  upon  the  good  sense  and  experience 
of  the  medical  attendant,  that  it  shall  not  be  subversive  of  domestic 
peace. 

Indeed,  it  has  occurred  in  more  instances  than  one,  within  our 
own  knowledge,  where  the  woman  has  thought  herself  the  injured 
party :  and  in  one  case,  the  recrimination  was  mutual.  In  this 
instance,  the  friends  of  the  parties  assembled  to  determine  on  the 
terms  of  separation ;  when  it  was  suggested  by  one  of  them,  who 
happened  to  be  more  rational  than  the  rest,  that  before  they  pro- 
ceeded to  such  an  extremity,  their  family  physician  should  be 
consulted;  a'nd  that  it  should  be  left  to  him  to  determine,  whether 
there  really  was  any  cause,  from  the  nature  of  the  disease  in  ques- 
tion, to  justify  such  a  measure.  We  were  accordingly  sent  for. 
We  gave  an  attentive  hearing  to  both  sides  of  the  question.  From 
what  was  related,  we  were  at  once  of  the  opinion,  that  there  was 
not  the  slightest  ground,  for  either  to  be  charged  with  a  want  of 
fidelity.  We  requested  to  speak  to  the  gentleman  in  private : 
when  he  withdrew,  we  solicited  an  examination  of  the  parts  sup- 

1  Dr.  Waller  recommends  a  solution  of  5  or  10  grains  of  the  nitrate  of  silver  to 
the  ounce  of  water  as  an  injection. 


52  PRURITUS. 

posed  to  be  so  much  injured,  and  found  the  prepuce  and  glans 
penis  in  the  condition  stated  above. 

From  the  appearance  of  the  penis,  we  were  convinced  that  the 
lady  had  nothing  but  "pruritus;"  and  we  assured  the  husband  that 
this  was  the  case  ;  and  upon  a  private  conversation  with  the  lady, 
we  were  confirmed  in  the  opinion  given  to  the  husband  ;  and  also 
fortunate  enough  to  make  her  suspend  all  further  proceedings,  if 
not  entirely  to  satisfy  her  that  she  had  nothing  to  apprehend,  as 
we  had  previously  done  with  the  husband. 

It  was  mutually  agreed,  therefore,  that  no  further  steps  should 
be  taken  in  the  business ;  in  the  mean  time,  we  were  to  satisfy 
each  that  they  had  nothing  to  complain  of.  The  borax  wash  and 
injections  were  ordered  for  the  wife;  and  for  the  husband,  the 
borax  wash  alone.  In  three  or  four  days  both  one  and  the  other 
were  perfectly  well ;  and,  to  this  moment,  most  happy  in  the  ex- 
planation they  had  so  fortunately  received. 

Chambon1  describes  a  variety  of  pruritus  which  we  have  never 
seen :  it  is  where  the  neck  of  the  uterus  is  the  seat  of  the  itching. 
As  we  have  never  met  with  this  case,  we  shall  employ  his  own 
description  of  it.  "  Le  prurit  du  col  de  lamatrice  est  plus  into!6- 
rable  qui  celui  de  la  vulve,  parce  qu'on  ne  peut  satisfaire  le  desir 
de  grater  cette  partie.  Quand  il  est  porte  a  un  certain  degre  d'in- 
tensitS,  il  cause  un  emportement,  une  apparence  de  fureur,  et  des 
movemens  convulsifs,  des  distorsions  du  tronc,  des  gonflemens  du 
has  ventre,  et  des  suffocations  semblables  &  celes  qu'on  remarque 
dans  la  passion  histerique.  Les  femmes  qui  voient  leurs  maris 
dans  cet  etat,  deviendroient  furieuses,  si  la  liqueur,  seminale  de 
1'un  et  de  1'autere  ne  temp6roit  pas  la  chaleur  du  col  de  la  uterus." 

He  recommends  no  particular  treatment  for  this  affection  ;  nor 
indeed  for  the  other,  save  the  most  feeble  that  can  well  be  ima- 
gined; as  bathing,  fumigations,  and  injections,  together  with  de- 
coctions of  some  of  the  mucilaginous  grains,  as  flaxseed,  quince- 
seed,  &c. 

Dr.  Denman  says,  "  When  this  complaint,  independently  of 
pregnancy,  originates  from  an  affection  of  the  uterus,  and  is  of 
long  continuance,  the  application  must  be  varied,  and  such  medi- 
cines given  as  promise  relief  by  changing  the  state  of  that  part. 
Sulphur,  taken  internally,  has  sometimes  been  of  much  service  ; 
or  applied  to  the  part  as  a  powder,  liniment,  or  lotion.  The  burnt 
sponge,  with  nitre,  and  the  extracturn  cicutse,  have  also  been 
given  with  advantage  ;  together  with  a  lotion  composed  of  equal 
parts  of  the  aqua  zinci  vitriolati  cum  camphora  and  rose  water; 
or  the  application  of  the  ung.  hydrargyr.  fort.  I  have  also  fre- 
quently given  five  grains  of  Plummer's  pill  every  night  at  bed- 

'  Des  Maladies  des  Filles,  vol.  ii.,  p.  73. 


PRURITUS.  53 

time  for  a  month,  and  a  pint  of  the  decoction  of  sarsaparilla  daily ; 
though  there  was  no  suspicion  of  any  venereal  infection."1 

Dr.  Denman  farther  observes,  "  It  is  sometimes  occasioned  by 
a  disease  or  affection  of  the  bladder,  and  is  then  equivalent  to 
the  itching  of  the  glans  penis  in  men. — When  this  complaint  has 
been  occasioned  by  an  affection  of  the  bladder,  the  constant  or 
daily  use  of  a  bougie  in  the  urethra  has,  in  some  cases,  effectually 
cured  the  patient."2 

In  young  female  children,  we  very  often  witness  an  inflammation 
and  swelling  of  the  labia,  accompanied  by  a  discharge  of  rather 
a  purulent  appearance,  attended  by  great  and  frequent  itching. 
To  relieve  which,  they  rub  the  parts  violently,  and  even  in  sleep, 
until  they  become  denuded  sometimes  of  the  cuticle.  This,  how- 
ever, I  believe,  never  happens,  but  where  there  is  a  great  neglect 
of  cleanliness ;  at  least  frequently  washing  the  parts  with  warm 
water  has  always  cured  it. 

Dr.  Denman  also  says,  that  "  those  women  who  carry  dead 
children  are  more  subject  to  this  disease  than  those  who  carry 
living  children."  This  remark  is  not  confirmed  by  my  own  ex- 
perience. I  have  known  many  instances,  where  dead  children 
were  carried,  without  this  disease  being  present;  and  I  have 
known  a  number  of  cases  of  pruritus,  where  the  children  were 
certainly  born  alive, 

Gardien  recommends  the  application  of  blisters,  in  those  cases 
of  pruritus  which  proceed  from  a  dartrous  eruption.  He  says, 
"  Si  ce  prurit  derive  d'une  dartre  fix6e  vers  ce  lieu,  on  ne  peut 
attendre  de  soulagement  que  des  m6dicamens  propres  4  changer 
1'etat  de  la  malade,  telsque  les  bains  sulfureux,  1'usage  int£rieur 
du  soufre,  et  autres  moyens  adaptes  a  la  nature  de  1'affection. 
Un  v6sicatoire  plac6  u  la  partie  interne  de  la  cuisse  est  souvent 
lemoyens  le  plus  sftr  de  deliver  la  femme  de  ce  prurit  en  depla9ant 
la  dartre;  on  pourrait  1'appliquer  sur  les  grandes,  levres  memes, 
pour  changer  la  mode  de  sensibilite  de  la  partie  en  y  §tablissant 
momentanement  un  autre  mode  de  douleur." — Traite  Complete, 
vol.  i.  p.  73. 

i.:         I'    .,  .':—••••;•'./!,•-    v,<--    t;      .ji,'       •:    •     ,'     .1    t. 

1  Introduction  to  Midwifery.    Francis's  ed.  p.  109.  *  Ibid. 


54  DISEASES  OP  THE   VAGINA. 

CHAPTER  III. 

OP  THE  DISEASES  OP  THE  VAGINA. 
. .  *?  .•   .'  ;-.fs'.i    .,1]  »•-•*.  •  "  •  t''i"'I  >J}i1j'>°ii.'   y.'i   1  {  'l''LK'"'.    i?     :,.!  '«'••'  *' 

''       I '        T 

THE  diseases  of  the  vagina  may  be  either  natural  or  accidental. 
The  natural  consist,  agreeably  to  Dr.  Denman,  of  "  such  an  ab- 
breviation or  contraction  as  to  render  it  unfit  for  the  purposes  for 
which  it  was  designed." *  We  have  never  encountered  more  than  one 
such  case;  and  this  was  not  so  excessive  as  altogether  to  destroy 
the  usefulness  of  the  part.2  A  great  difficulty  was  at  first  ex- 
perienced from  coition ;  but  this  gradually  lessened,  though  never 
altogether  removed.  Upon  examination,  it  was  found  to  be 
difficult  to  pass  the  finger  unless  the  parts  were  previously  well 
lubricated;  and  this  expedient  was  always  necessary,  before 
each  conjugal  consummation.  The  os  uteri  was  found  just 
within  the  os  externum;  and  the  whole  distance  to  which  the 
finger  could  be  passed,  did  not  exceed  an  inch,  or  an  inch  and  a 
half. 

This  person  was  barren,  but  extremely  anxious  to  be  fruitful ; 
aware  of  some  natural  defect,  she  submitted  to  the  examination 
which  led  to  the  knowledge  of  what  has  been  just  stated.  As 
there  was  nothing  to  be  done  in  this  case,  the  parts  were  left  un- 
disturbed by  any  attempts  to  dilate  the  contracted  passage. 

In  greater  departures,  Dr.  Denman  says,  "The  curative  indi- 
cations are  to  relax  the  parts  by  the  use  of  emollient  applications, 
and  to  dilate  them  to  their  proper  size  by  sponge  or  other  tents, 
or,  which  are  more  effectual,  by  bougies  gradually  enlarged." 

Dr.  Denman  informs  us,  that  in  a  case  of  this  kind,  the  efforts 
of  the  husband  to  overcome  the  resistance  of  the  parts,  so  irritated 
them  as  to  produce  a  purulent  discharge  from  them,  which  was 

'  Morgagni  mentions  a  case  in  which  the  vagina  was  only  one-third  of  the 
common  length;  this  was  terminated  by  a  firm  fleshy  substance — this  woman 
was  barren.  "  Columbus  dissected  a  woman  who  always  complained  of  great 
pain  in  coitu.  The  vagina  was  very  short,  and  had  no  uterus  at  its  termination." 
Burns,  p.  87. 

1  Since  writing  the  above,  a  woman  of  thirty-five  years  of  age  presented  her- 
self for  advice.  She  informed  me  she  never  had  menstruated,  nor  had  felt  any 
symptoms  that  would  indicate  it.  She  had  been  married  nine  years,  had  all  the 
marks  of  womanhood;  was  not  averse  to,  but  rather  enjoyed  sexual  intercourse ; 
but  never  became  pregnant.  Upon  an  examination  per  vaginam,  this  canal  was 
found  narrow,  and  about  an  inch  and  a  half  in  depth,  terminating  in  a  cul-de-sac. 
Nothing  like  a  uterus  could  be  felt.  We  have  said,  this  woman  had  never  been 
impregnated;  not  because  she  had  an  imperfect  vagina,  but  because  there  was 
no  evidence  of  a  uterus;  at  least  not  of  a  healthy  one;  for  had  there  been  one,  the 
menses  would  certainly  have  been  secreted:  and  she  might  have  been  relieved  by  an 
operation. 


LEUCOERHCEA.  55 

mistaken  for  a  venereal  affection.  The  inflammation  was  sub- 
dued by  the  ordinary  means,  and  living  for  a  time  absque  marito ; 
the  parts  were  afterwards  dilated  by  means  of  tents  and  bougies 
of  various  sizes.  After  her  return  to  her  husband,  she  became 
pregnant;  and  was  safely  delivered,  after  a  slow,  but  not  an  uncom- 
mon labour. 

The  accidental  consists  of  cohesions  of  the  sides  from  previous 
ulceration ;  and  of  cicatrices  after  such  ulcerations. 

The  difficulties  arising  from  such  causes  are  severely  felt  in 
the  time  of  labour,  as  they  are  rarely  of  such  extent  as  to  inter- 
rupt coition.  The  time  to  be  useful  in  such  cases  is,  before  the 
parts  heal ;  if  attended  to  then,  much  mischief  may  be  avoided  by 
the  proper  use  of  tents,  &c.  During  labour  extensive  bleeding 
seems  to  be  the  only  remedy.  See  System  of  Midwifery,  chapter 
on  Tedious  Labour,  by  the  author. 


CHAPTER  IV. 


OF  LEUCORRHCEA. 

THIS  complaint  has  been  familiar  to  the  practitioner  from  the 
time  of  Hippocrates  to  the  present  moment;  yet  it  is  not  so  well 
understood  as  always  to  ensure  the  patient  a  certainty  of  cure. 
Indeed  this  affection,  even  at  the  present  day,  is  ranked  by  many 
among  the  opprobia  medicorum.  Women  seem  to  be  obnoxious 
to  leucorrhoea  in  every  known  climate ;  and  in  every  situation  of 
life,  she  is  more  or  less  exposed  to  its  occurrence.  So  decidedly 
is  this  the  case,  (at  least  in  civilized  life,)  that  the  woman  who 
has  not  had  the  complaint,  appears  to  have  escaped  from  an  im- 
pending mischief,  rather  than  to  have  been  constitutionally  en- 
titled to  the  exemption.  Yet  some  are  more  obnoxious  to  it  than 
others;  and  this  difference  arises  principally  from  the  following 
causes : — 

First.  Original  constitution  or  temperament:  thus,  women  of 
the  sanguine  temperament  and  rigid  fibre  are  less  liable  to  this 
complaint,  than  those  who  are  fair-skinned,  light-haired,  and  of  a 
relaxed  fibre. 

Second.  Location,  atmosphere,  and  occupation,  have  their 
influence,  or  so  modify  common  agents,  as  to  render  them  capa- 
ble of  producing  it.  Thus  women  of  high  and  mountainous 
countries,  who  enjoy  a  pure  and  dry  air,  are  freer  from  this 
complaint  than  those  who  inhabit  a  moist  and  cold  climate. 


56  LEUCORRHCEA. 

Also,  those  who  live  in  the  country,  and  who,  from  the  nature  of 
their  occupations,  are  obliged  to  use  much  exercise,  are  less 
visited  by  this  scourge  than  the  indolent  women  of  large  cities; 
hence,  women  of  very  sedentary  habits,  and  who  indulge  in  luxu- 
rious idleness,  are  almost  sure  to  have  this  complaint.  Mr. 
Churchill  seems  to  imply  that  the  uterine  leucorrhoaa  is  as  com- 
mon, or  more  so,  than  vaginal — which  if  it  be  a  fact  in  England 
is  not  so  here ;  indeed  we  consider  this  form  of  the  disease  to  be 
extremely  rare,  agreeably  to  the  experiments  of  ourselves. 

Third.  Habits  of  life,  and  the  quality  and  quantity  of  nourish- 
ment, will  have  an  operation  upon  all  constitutions  or  tempera- 
ments. Thus  women  who  indulge  much  in  bed,  who  keep  late 
hours,  who  over-stimulate,  who  drink  immoderately  of  thin,  un- 
nourishing  drinks,  as  tea  and  coffee,  are  more  disposed  to  this 
discharge,  than  those  who  observe  a  contrary  plan;  and  such 
are  especially  liable  to  it,  who  use  the  warm  bath  too  freely,  or 
are  in  the  habit  of  employing  "  foot  stoves."  Hence,  the  women 
of  Holland  are  particularly  liable  to  leucorrhoea;  as  their  climate, 
habits,  and  nourishment,  all  dispose  to  it. 

Fourth.  Habits  of  cleanliness  will  tend  very  much  to  preserve 
the  parts  concerned  from  this  discharge,  even  in  those  who  may 
be  disposed  to  it;  while  the  neglect  of  this  physical  virtue  will 
be  almost  sure  to  produce  it,  even  in  those  not  otherwise  disposed 
to  it. 

At  all  periods  of  life,  females  are  liable  to  an  increased  dis- 
charge from  the  vulva;  thus,  we  witness  it  in  the  infant  girl,  and 
in  the  aged  matron,  but  not  equally  often  in  both;  it  is  more  fre- 
quently found  with  the  latter  than  with  the  former.  This  com- 
plaint frequently  commences  about  puberty — it  may,  therefore, 
anticipate,  accompany,  or  follow  the  menstrual  secretion ;  but,  at 
this  period,  it  is  of  but  temporary  continuance,  for  the  most  part, 
unless  great  errors  have  been  committed  in  the  management  of 
the  female  at  this  time;  or  unless  there  should  be  a  particular 
predisposition  to  the  complaint,  from  hereditary  taint,  or  original 
temperament.1 

As  the  woman  advances  in  life,  and  after  she  has  become  a 
mother;  when  her  necessities  demand  great  exertion,  and  pre- 
vent proper  indulgences  during  pregnancy,  and  after  labour,  she 
is  more  particularly  liable  to  it,  than  at  any  other  period ;  and 
then  generally  in  its  worst  forms.  Hence,  women  in  the  lower 
walks  of  life  are  more  obnoxious  to  leucorrhoea  than  those  who 

1  Gardien,  and  some  others,  think  leucorrhoea  is  sometimes  hereditary;  he  says, 
"  Le  catarrhe  uterin  peut  attaquer,  des  le  has  Age,  les  filles  qui  ont  eu  pour  meres 
des  femes  sujettes  habituellement  a  un  6coulement;  mais  cette  leucorrhee  hereditaire 
ne  pent  pas  etre  distinguee  de  celle  qui  est  entretenue  par  la  debilite  de  la  constitu- 
tion: comme  cette  derniere,  elle  depend  de  1'organisation  primitive,  qui  est  faible  et 
lache."  Traite  Complete,  &c.,  vol.  i.  p.  321. 


LEUCORRH<EA.  57 

indulge  in  what  the  others  cannot  enjoy;  provided  the  latter  do 
not  abuse  these  privileges  and  comforts. 

Women  who  are  constantly  exposed  to  the  abuse  of  venery, 
from  their  calling  or  their  necessities;  or  those  who  may  too 
freely  indulge  in  the  gratifications  of  love  without  that  necessity: 
and  especially  those  who  selfishly  abuse  the  enjoyment,  are  always 
obnoxious  to  leucorrhosa. 

Those  who  may  suffer  from  long-protracted  and  difficult  la- 
bours, or  who  may  have  been  under  the  necessity  of  yielding 
to  artificial  modes  of  delivery;  those  who,  from  the  relaxation 
of  the  system  generally,  and  the  uterine  in  particular,  have 
sudden  labours;  those  who  have  become  debilitated  from  me- 
norrhagia,  diarrhoea,  hemorrhoids,  or  who  labour  under  irregu- 
larity, or  suppression  of  the  menses,  are  ever  prone  to  this  com- 
plaint. 

Nervous  and  hysterical  women  are  also  liable  to  this  com- 
plaint: it  may  not  commence  with  these  affections,  though  it  is 
pretty  sure  to  follow  them ;  especially  if  great  irritability  of  tem- 
per accompany,  and  this  indulged  in,  by  giving  vent  to  sudden 
bursts  of  passion,  or  displays  of  bad  humour. 

Some  are  of  opinion,  that  the  season  of  the  year  has  consider- 
able influence  on  this  discharge.  Leake  says,  "  I  have  attended 
more  patients  labouring  under  fluor  albus  in  autumn  than  at  any 
other  season  of  the  year,  especially  when  the  weather  was  un- 
commonly moist  and  cold."  Diseases  of  Women,  vol.  i.  p.  107. 
I  have  never  observed  this  influence ;  and  I  am  rather  disposed 
to  believe  it  accidental  if  it  occur.  A  disease  of  such  long  stand- 
ing as  leucorrhoea  almost  always  is;  one  for  the  most  part  so 
obstinately  confirmed  by  local  irritation  and  habit,  is  not  very 
likely  to  be  influenced  by  mere  change  of  temperature,  or  moist- 
ure. It  is  not  a  sufficient  explanation  of  this  (perhaps  assumed) 
fact,  to  say,  that  the  surface  which  yields  the  discharge  is  like 
those  mucous  membranes  which  are  affected  by  the  changes  of 
the  atmosphere;  and  may  like  them  be  attacked  by  inflamma- 
tion, and  urged  to  an  increase  of  discharge ;  for  from  their  loca- 
lity and  perfect  defence  against  the  vicissitudes  of  season,  they 
cannot  be  very  liable  to  their  influence.  I  fear  there  is  rather  too 
much  refinement  in  these  opinions,  to  be  confirmed  by  fact.1 

The  only  causes,  capable  of  influencing  this  discharge,  as  far 
ns  I  have  been  able  to  ascertain,  are  those  which  affect  the  sys- 
tem at  large,  or  the  uterus  in  particular ;  such  as  fever ;  passions 

'  The  mucous  membranes  very  generally  sympathize  with  impressions  made 
upon  the  skin;  thus,  the  lining  of  the  trachea;  of  the  nostrils;  of  the  throat;  of  the 
frontal  sinuses,  &c.,  are  very  often  brought  into  morbid  action,  through  the  me- 
dium of  the  skin,  by  the  changes  in  atmospheric  temperature;  but  the  uterus  and 
vagina,  we  believe,  are  very  rarely  affected  by  such  vicissitudes,  however  strongly 
they  may  affect  the  external  surface. 


58  LEUCORRHCEA. 

or  emotions  of  the  mind ;  too  stimulating  diet ;  gastric  irritations ; 
the  approach,  and  the  cessation  of  the  menstrual  discharge  at 
each  period;  pregnancy;  and  excessive  coition.  Now,  all  the 
causes  just  enumerated  will  be  acknowledged  capable  of  such  a 
consequence,  since  the  whole  arterial  system  is  acted  upon ;  and 
of  course  the  uterus  and  vagina,  constituting  important  portions 
of  the  general  system,  must  partake  of  the  general  effect. 

I  know  several  ladies,  who  are  not  habitually  liable  to  fluor 
albus,  yet  will  be  attacked  by  this  discharge,  whenever  their 
systems  are  excited  by  fever.  Others  will  have  an  immediate 
leucorrhoeal  discharge,  when  angered,  alarmed  or  overjoyed. 
Others  upon  drinking  a  glass  of  wine,  extraordinary,  or  eating 
very  highly  seasoned  victuals,  will  feel  an  increase  of  vaginal 
secretion;  others,  when  their  stomachs  are  acid,  or  otherwise 
irritated,  will  have  fluor  albus  more  abundantly;  very  many  are 
only  sensible  of  the  existence  of  this  disposition  of  the  vagina, 
just  before  the  eatamenia  are  about  to  take  place,  or  immediately 
after  they  have  ceased.  Most  women  who  are  accustomed  to 
leucorrhoea,  will  have  an  augmented  discharge  when  pregnant; 
while  some  will  have  it  at  no  other  time;  and  ail  perhaps  will  have 
it  more  abundant  after  too  great  venereal  indulgence. 

Almost  all  the  authorities  I  have  consulted  on  the  subject  of 
leucorrhoea,  make  it  a  constitutional  disease;  and  hence  the  nu- 
merous causes  assigned  for  its  origin ;  and  hence  the  multiplication 
of  species  and  varieties  by  systematic  writers. 

Thus  Pinel  enumerates — 

1st.  The  constitutional. 

2d.  The  accidental. 

3d.  The  vicarious. 

4th.  The  syphilitic. 

5th.  The  critical.1 

While  Blattin,  who  has  written  a  very  long  and  erudite  work 
upon  the  subject,  wishes  to  add  to  the  above — 

6th.  From  derangement  of  the  menses. 

7th.  Hereditary. 

8th.  From  indigestion. 

Gardien,  however,  makes  but  three — 

1st.  Leucorrhosa  from  irritation. 

2d.   Constitutional  or  adynamic. 

3d.  Metastatic  leucorrhoea;  but  observes,  he  would  think  it 
proper  to  add  to  these  three  species  two  others,  where  leucorrhoea 
is  only  symptomatic;  one  of  these  he  would  call  "spasmodic  leu- 
corrhoea," and  the  other  "sympathetic  leucorrhoea." 

That  a  variety  of  causes  may  dispose  the  uterus  and  vagina  to 
take  on  the  leucorrhoeal  action,  we  have  no  hesitation  to  believe; 

1  Diet,  des  Scien.  Med.  art.  Leucorrhoea. 


LEUCORRHCEA.  59 

but  the  production  of  the  complaint  requires  an  immediate  exciting 
cause,  and  that  cause  must  be  of  an  irritating  kind.  I  would 
therefore  only  acknowledge — 

1st.  The  leucorrhoea  of  direct  irritation. 

2d.  The  leucorrhoea  of  remote  or  indirect  irritation. 

3d.  The  leucorrhoea  of  habit. 

I  can  form  no  idea  of  Pinel's  first  species ;  that  is,  I  have  no 
conception  of  any  separate  or  distinct  constitutional  power,  which, 
independently  of  local  irritation,  shall  produce  the  disease  in 
question;  or,  in  other  words,  thus  to  influence  the  mucous  mem- 
brane of  the  vagina  and  uterus,  to  an  inordinate  secretfon. 

His  second  species  must  necessarily  comprise  the  exciting,  or 
local  cause ;  if  so,  it  becomes  the  leucorrhoea  of  direct  or  indirect 
irritation ;  for  the  parts  are  only  accidentally  or  fortuitously  irri- 
tated, and  brought  into  diseased  action. 

His  third,  or  the  vicarious,  we  have  never  witnessed,  if  we 
comprehend  the  term ;  that  is,  leucorrhcea  by  metastatis,  or  by  an 
assumption  of  action.  Yet  we  are  not  prepared  to  deny  the 
possibility  of  such  a  condition  of  the  uterus  and  vagina;  for  me- 
tastases  are  not  unfrequent  in  arthritic  or  rheumatic  constitutions; 
or  where  there  has  been  a  suppression  of  an  accustomed  evacua- 
tion, it  may  happen  that  other  parts  may  assume  a  morbid  ac- 
tion. But  if  this  be  admitted,  it  will  only  prove  that  there  has 
been  a  transfer  of  irritation;  consequently  it  forms  "the  leucor- 
rhoea of  irritation." 

His  fourth,  or  "syphilitic,"  is  obviously  the  product  of  irrita- 
tion ;  the  syphilitic  virus  being  the  remote  cause,  the  irritation 
consequent  upon  its  application  produces  an  increase  of  discharge 
from  the  surface  to  which  it  is  applied ;  but  this  discharge  is  one 
of  a  specific  nature,  and  not  the  matter  discharged  in  common 
leucorrhoea;  therefore,  it  is  nothing  more  nor  less  than  syphilis 
itself,  so  long  as  the  syphilitic  action  continues.  But  after  a  time 
the  surface  may  cease  to  secrete  a  morbid  poison ;  though  an  ir- 
ritation of  sufficient  force  continue  to  maintain  an  increased  se- 
cretion ;  therefore  the  disease,  in  this  last  form,  is  the  leucorrhoea 
of  direct  irritation  and  habit. 

His  fifth,  or  "critical,"  may  exist:  we  have  never  witnessed 
it;  but  if  it  occur,  it  must  necessarily  resemble  his  "vicarious," 
in  its  general  phenomena;  and,  like  it,  becomes  a  leucorrhoea  of 
irritation. 

Those  added  by  Blattin  resolve  themselves  into  the  same  spe- 
cies, or  the  leucorrhoea 'of  irritation;  therefore  the  sixth,  or  that 
from  disordered  menstruation,  becomes  the  leucorrhoea  of  indi- 
rect irritation ;  while  the  seventh  is  only  a  modification  of  Pi- 
nel's  first  or  constitutional  leucorrhoea,  which,  like  it,  can  only 
produce  predisposition ;  for  we  do  not  believe  that  children  are 
ever  born  with  this  disease  upon  them,  or  even  subject  to  it  very 


60  LEUCORRIKEA. 

soon  after  birth ;  and,  were  this  even  the  fact,  it  might  not  be  dif- 
ficult to  account  for  it,  provided  the  mother  was  labouring  under 
the  affection  at  the  time  of  the  child's  birth ;  for  the  matter  of 
leucorrhoea  might  be  applied  to  the  child  in  transitu,  and  produce 
the  disease,  as  it  does  sometimes  purulent  ophthalmia. 

His  eighth,  or  "leucorrhoea  from  indigestion,"  must  necessarily 
be  considered  a  disease  of  sympathy,  or  leucorrhoea  of  indirect 
irritation ;  since  the  source  of  irritation  is  the  disordered  stomach, 
with  which  the  uterus  and  vagina  sympathize. 

The  division  of  Gardien  is  much  less  exceptionable;  for  he 
reduces  the  species  to  three.  His  first,  or  the  leucorrhoea  of  ir- 
ritation, we  cheerfully  adopt,  as  it,  strictly  speaking,  comprehends 
every  thing.  His  second  is  exceptionable,  as  it  is  but  a  modifi- 
cation of  Pinel  and  Blattin.  We  have  no  idea  of  a  disease  of  pure 
weakness.  His  third  is  an  adoption  of  the  third  of  Pinel,  and  of 
course  liable  to  the  same  objections. 

In  a  practical  point  of  view,  very  little  is  gained  by  the  multi- 
plication of  knowledge  of  the  remote  causes  of  disease;  and  it  is 
fortunate,  in  a  general  sense,  that  it  is  so — for  were  an  absolute 
knowledge  of  the  remote  cause  essential  to  the  cure  of  the  proxi- 
mate or  the  disease  itself,  we  should  be  much  less  successful  in 
the  cure,  thaa  we  are  at  present ;  for,  in  very  many  instances,  we 
are  entirely  ignorant  of  the  remote  cause. 

In  the  "  leucorrhoea  from  derangement  in  the  digestive  organs," 
(if  it  really  exist,)  the  knowledge  of  the  fact  might  be  useful ;  as 
the  remedies  calculated  to  alter  the  condition  of  these  organs 
should  be  addressed  to  them,  with  a  view  to  destroy  the  source 
of  irritation,  and  thus  diminish  the  intensity  of  sympathy.  In  the 
case  under  consideration,  much  uncertainty  would  exist,  whether 
the  long-continued  discharge  from  the  vagina  is  not  the  cause  of 
the  derangement  of  stomach,  as  in  chlorosis,  rather  than  the  de- 
rangement of  stomach  the  cause  of  the  discharge  from  the  va- 
gina. Gardien  declares,  "Le  derangement  des  digestions  ac- 
compagne  constamment  la  Ieucorrh6e  constitutionnelle.  Les 
tiraillement  d'estomac  ont  aussi  toujours  lieu  dans  le  catarrhe 
ute>in  chronique,"  p.  332.  But  this  offers  no  illustration,  or  ex- 
planation, of  which  is  the  cause,  or  which  is  the  effect.  Be- 
sides, we  feel  rather  disposed  to  doubt  the  frequency  of  this  com- 
bination; for  of  one  thing  we  are  certain,  that  we  have  seen 
many  instances  of  leucorrhoea  without  derangement  of  stomach ; 
and  we  have  as  certainly  seen  many  cases  of  dyspepsia,  without 
leucorrhoea.  Indeed,  he  seems  to  confess,  that  causes  are  ad- 
mitted with  too  much  facility;  for  he  immediately  after  adds, 
"  Les  causes  predisposantes  et  determinantes  du  catarrhe  uterin 
sont  extrement  vari6es :  peut-etre  pourrait — on  reproche"r  aux 
auteurs  d'en  avoir  adinis  plusieurs  trop  legerement,  et  d'avoir 
souvent  conclu  post  hoc,  Ergo  propter  hoc.  Dans  la  recherche 


§ 

LEUCORRH03A.  61 

des  causes,  on  a  souvent  regard^  comme  lies  deux  phenomenes  qui ' 
n'etaient,  que  coexistans,"  p.  322. 

In  the  syphilitic  leucorrhoea,  as  it  is  called,  it  woujd  also  be 
useful  to  know  of  its  existence;  since  syphilis  itself  would  re- 
quire a  distinct  treatment  from  common  leucorrhoea ;  in  this  case, 
the  disease,  as  just  observed,  would  not  be  leucorrhoea  but  syphilis, 
during  the  active  stage ;  but  the  remote  effects  would  require  no 
specific  treatment,  as  the  leucorrhoea  following  syphilis  would 
yield  to  the  same  remedies  as  leucorrhoea  from  any  other  cause. 

Gardien's  occasional  extension  of  species  into,  1st,  sympathe- 
tic leucorrhoea;  2d,  spasmodic  leucorrhcea,  answers  no  good  pur- 
pose whatever  in  practice;  especially  as  there  is  no  satisfactory 
evidence  of  the  existence  of  the  latter;  and  the  first  will  naturally 
range  itself  under  the  head  of  leucorrhoea,  from  remote  or  indirect 
irritation. 

He  tells  us,  (with  what  propriety  the  profession  must  judge,) 
"J'ai  donne  le  nom  spasmodiques,  a  celles  qui  surviennent  chez 
de  jeunes  personnes,  pour  avoir  pris  du  lait,  ou  pour  avoir  fait 
usage  de  compositions  emmenagogues,"  p.  319. 

The  division  we  have  made,  we  think,  can  be  defended,  by  both 
reason  and  practical  observation. 

Under  the  first  head,  or  "the  leucorrhoea  of  direct  irritation," 
we  would  consider  all  such  instances  of  this  discharge  as  follow 
an  active  inflammation  of  the  mucous  membrane  of  the  uterus  or 
vagina  produced  by  some  local  cause :  as  laborious  parturition ; 
application  of  instruments ;  excess  of  venery;  irritating  substances 
applied  to  the  surface  of  the  vagina;  extraneous  bodies  intro- 
duced into  it ;  a  prolapsed  uterus ;'  tumours  within  the  vagina ; 
injections  of  too  stimulating  a  kind ;  or  from  the  simple  inflamma- 
tion of  the  parts,  as  every  portion  of  the  body  is  liable  to  such 
attacks,  without  our  being  able  to  determine  why  this  or  that 
part  may  have  been  Selected.  We  have  known,  in  a  number  of 
instances,  leucorrhoea  to  follow  a  lingering  or  tedious  labour,  both 
where  instruments  may  have  been  used,  and  where  they  were 
not,  &c. 

Under  the  second  head,  or  "the  leucorrhoea  of  remote,  or  indi- 
rect irritation,"  we  would  range  all  such  instances  in  which  the 
vagina  sympathizes  with  some  other  portions  of  the  body;  as 
with  the  uterus  during  pregnancy;  or,  in  long-obstructed  menses; 
producing,  or  becoming,  what  is  called  chlorosis ;  as  when  the 
menstrual  action  is  about  to  furnish  the  catamenial  discharge,  or 
just  after  that  action  has  ceased.  With  the  rectum,  when  subject 
to  hemmorrhoids,  or  when  irritated  by  ascarides ;  with  the  gums, 
as  in  early  dentition ;  with  the  stomach,  when  dyspeptic,  &c. 

Under  the  third,  or  "leucorrhcea  of  habit,"  we  would  enume- 

1  Of  this  particular  cause,  we  have  had  occasion  to  speak  under  the  head  of 
"  Prolapsus  Uteri,"  which  see. 


62  LEUCORRHCEA. 

rate  those  instances,  which  continue  after  the  active  or  inflam- 
matory condition  of  the .  parts  has  ceased ;  as  after  syphilis  or 
gonorrhoea,  and  become  like  "gleet"  in  the  male;  a  prolapsed 
uterus  restored;  or  a  tumour  removed;  for  the  vessels  of  the 
uterus  and  vagina  seem  to  have  less  recuperative  power  than 
any  other  portions  of  the  body.  Almost  every  part  of  the  body, 
which  is  susceptible  of  action,  may  have  that  action  to  continue 
after  it  has  been  once  excited,  though  the  exciting  cause  be  re- 
moved ;  we  witness  it  in  the  nervous  and  muscular  systems,  as 
in  chorea,  hooping-cough,  &c. ;  in  the  vascular  and  glandular 
systems,  as  in  the  continuance  of  spitting,  after  the  action  of 
mercury  has  ceased;  in  the  membranous  and  vascular  systems, 
as  the  discharge  of  mucus  after  dysentery;  and,  agreeably  to 
Mr.  Hunter,  as  in  the  gleet  after  gonorrhoea.  He  distinguishes 
the  condition  of  the  mucous  membrane  of  the  urethra  in  gonor- 
rhoea, and  in  gleet,  in  the  following  manner.  "The  venereal  in- 
flammation is  of  such  a  nature  as  to  go  off  of  itself,  or  to  wear 
itself  out ;  or,  in  other  words,  it  is  such  an  action  of  the  living 
powers  as  can  subsist  but  a  given  time.  But  this  is  not  the  case 
with  a  gleet,  which  seems  to  take  its  rise  from  a  habit  of  action 
which  the  parts  have  contracted ;  as  they  have  no  disposition  to 
lay  aside  this  action,  it  of  course  is  continued ;  for,  we  find  in 
those  gonorrhoeas  which  last  long,  and  are  tedious  in  their  cure, 
that  this  habit  is  more  rooted  than  in  those  which  go  off  soon." 
Treatise  on  the  Ven.  Dis.  art.  Gleet. 

It  is,  in  many  instances,  precisely  the  same  in  leucorrhoea:  the 
mucous  membrane  of  the  vagina  may  be  irritated  by  a  sponta- 
neous inflammation;  by  mechanical  agencies;  by  acrid  substances; 
by  morbid  poisons;  or  perhaps  by  some  sympathetic  influence, 
so  as  to  produce  leucorrhoea.  The  irritating  causes  may  neverthe- 
less be  altogether  withdrawn ;  yet  the  surface  which  had  for  so 
long  a  time  continued  to  produce  the  fluor  albus,  will  from  habit 
persevere  in  its  production.  Hence,,  the  leucorrhoea  of  long 
standing  is  always  much  more  difficult  to  overcome,  than  the 
one  which  is  in  its  primitive  and  active  condition.  But  this  last 
species,  it  may  be  remarked,  very  rarely  occurs,  and  is  perhaps 
more  common  after  gonorrhoea,  than  after  any  other  cause. 

Gardien  seems  desirous  to  establish  a  species  of  leucorrhoea, 
"purely  local;"  we  have  endeavoured  to  prove  them  all  to  be 
so:  but  in  this  effort  he  unquestionably  confounds  two  distinct 
conditions  of  the  mucous  membrane  of  the  vagina.  He  says, 
"The  acute  uterine  catarrh  is  a  purely  local  affection,  and  de- 
pends on  a  peculiar  irritation  of  the  genital  organs.  It  offers 
four  periods Jn  its  progress;  the  first  is  announced  by  an  itching, 
at  first  sliglit,  of  the  vulva  and  interior  of  the  vagina,  which  is 
occasionally  extended  to  the  womb.  The  woman  complains  of 
a  considerable  heat  in  the  vicinity  of  this  organ ;  of  a  feeling  of 


LEUCORRHCEA.  63 

dryness,  which  suspends  immediately  the  secretion  of  the  muco- 
sities  which  lubricate  the  vagina,  and  of  pains  of  the  back '  and 
loins;  the  itching  increases,  and  sometimes  becomes  insupporta- 
ble. In  some  cases  it  augments  the  sexual  appetite ;  if  this  dis- 
position be  yielded  to,  the  disease  is  aggravated.  This  period  is 
accompanied  by  frequent  disposition  to  pass  the  urine." 

"The  second  period,  which  takes  place  on  the  second  or  third 
day,  is  characterized  by  a  serous  discharge,  not  very  abundant 
at  first ;  this  augments  in  quantity,  and  assumes  a  green  or  yel- 
lowish colour,  varying  in  intensity  according  to  the  degree  of 
irritation;  the  ardor  urinse  becomes  more  fatiguing,  the  labia 
majora,  the  vagina,  and  sometimes  the  urethra,  show  signs  of 
inflammation.  Fever  sometimes  ensues;  the  pains,  at  first  con- 
centrated in  the  loins,  sometimes  extend  to  the  groins,  to  the 
haunches,  internal  part  of  the  thighs,  and  perineum." 

"In  the  third  period,  which  begins  on  the  ninth  or  tenth  day, 
the  intensity  of  the  inflammatory  symptoms  diminish ;  the  dis- 
charge is  still  very  copious ;  it  successively  becomes  thicker  and 
offers  shades  of  colour,  until  it  grows  entirely  white ;  then  it  soon 
diminishes,  and  the  ardor  urinse  suddenly  disappears." 

"  The  fourth  period,  which  forms  the  passage  to  the  chronic 
state,  presents  many  irregularities ;  the  discharge  disappears  for 
some  time,  and  returns  without  obvious  cause.  That  of  which  the 
matter  is  flocculent,  or  resembles  glairy  threads  or  jelly,  is  com- 
monly most  difficult  to  cure,"  p.  324. 

We  have  made  this  long  extract,  concerning  what  the  author 
terms  the  "leucorrhte  aigu,"  to  show,  that  he  confounds  almost 
all  the  discharges  from  the  vagina  under  one  general  head;  name- 
ly, "le  catarrhe  uterin;"  than  which  there  cannot  well  be  a  more 
obvious  error :  thus,  the  purulent  discharge  of  gonorrhoea ;  the 
mere  increase  of  the  natural  discharge,  or  the  temporary  aug- 
mentation of  it,  (which  he  considers  either  sympathetic  or  criti- 
cal,) he  classes  under  the  same  head,  but  looks  upon  them  as 
constitutional.  But  a  disease  which  he  admits  to  be  local  and  acute, 
and  of  which. we  have  given  his  own  account,  he  also  makes  a 
leucorrhoea ;  but  to  which  it  has  not  the  slightest  analogy,  either 
in  "its  symptoms,  or  in  the  method  of  cure;  for  the  disease  in 
question  consists  of  a  peculiar  inflammation,  and  oftentimes  an 
aphthous  condition  of  part  of  the  vagina,  and  of  the  vestibulum 
especially  ;  and  is  properly  a  variety  of  the  "  pruritus"  of  authors. 
See  section  on  Pruritus. 

The  discharge  constituting  leucorrhcpa  is  declared  by  authors 
to  proceed  from  the  uterus  and  vagina.  To  determine  this  point, 

*  All  that  portion  of  the  vulva,  which  is  anterior  to  the  hymen  in  virgins,  and 
the  carunculae  myrtiformes  in  those  who  are  not,  is  called  the  vestibulum. 


64  LEUCORRHCEA. 

may  not  appear  at  first  sight  to  be  of  much  consequence ;  yet  the 
practitioner  may  find  it  of  great  use  in  making  his  prescriptions; 
for  the  remedies  which  may  be  found  useful  in  the  one  instance, 
may  fail  altogether  in  the  other.  We  are  of  opinion,  that  this 
discharge  rarely  proceeds  from  the  cavity  of  the  uterus,  even  in 
its  most  aggravated  form ;  and  when  it  does,  it  must  always  be 
looked  upon  as  the  most  difficult  of  management. 

If  Dr.  Cullen's  definition  be  admitted,  leucorrhoea  would  be 
limited  to  the  internal  cavity  of  the  uterus  itself. 

He  says,  "  Every  serous  or  puriform  discharge  from  the  vagina 
may  be,  and  has  been,  comprehended  under  one  or  other  of  these 
appellations — leucorrhoea,  fluor  albus,  or  whites.  Such  discharges 
may  be  various,  and  may  proceed  from  various  causes,  not  yet 
well  ascertained  •  but  I  confine  myself  here  to  treat  of  those  dis- 
charges alone  which  may  be  presumed  to  proceed  from  the  same 
vessels  which  in  their  natural  state  pour  out  the  menses. 

From  this  definition  of  fluor  albus,  it  will  be  perceived  at  once 
that  a  pregnant  woman  cannot  have  this  complaint;  yet  the  fact 
is  notorious,  that  all  women,  (or  at  least  with  very  few  excep- 
tions, as  far  as  our  observations  have  extended,)  have,  during 
this  period,  a  greater  discharge  from  the  vagina  than  when  they 
are  not  pregnant:  and  many  have  not  this  discharge,  as  already 
noticed,  but  at  such  times.  Now,  the  discharge  which  continues, 
and  even  increases  during  pregnancy,  and  that  which  only  takes 
place  at  that  period,  cannot  be  leucorrhcea ;  or  Dr.  Cullen,  con- 
fining this  complaint  to  the  "  vessels,  which,  in  their  natural  state, 
pour  out  the  menses,"  must  be  wrong.  Astruc,  indeed,  declares, 
he  has  seen  both  leucorrhcea  and  the  menses  flow  at  the  same 
time. 

"I  conclude,"  says  the  doctor,  "a  discharge  from  the  vagina 
to  be  of  this  kind,  (namely,  from  the  vessels  which  furnish  the 
menses.)  1.  From  this  happening  to  women  who  are  subject  to 
an  immoderate  flow  of  the  menses,  and  liable  to  this  from  causes 
weakening  the  vessels  of  the  uterus." 

To  this  we  would  observe,  that  there  is  no  natural  connexion 
between  the  two  complaints,  as  stated  by  Dr.  Cullen;  for  our  ex- 
perience furnishes  us  with  so  many  exceptions  to  this  rule,  that 
we  cannot  look  upon  them  as  necessarily  associated :  we  have 
seen  many  instances  of  menorrhagia  without  leucorrhcea ;  and 
we  have  seen  more  cases  of  leucorrhcea  without  menorrhagia. 
Besides,  the  Doctor  attributes  this  discharge  following  immode- 
rate flows  of  the  menses,  to  "causes  weakening  the  vessels  of  the 
uterus."  It  is  an  evidence  of  weakened  vessels,  when  they  are 
forced  to  secrete  a  fluid  of  a  colour  and  quality  different  from 
that  of  the  natural,  and  at  the  same  time  very  much  more  abun- 
dant. Is  not  secretion  an  action ;  and  if  that  action  produces  a 
greater  quantity  of  a  material,  than  it  does  when  it  is  acknow- 


LEUCORRHCBA.  65 

ledged  to  be  in  health,  would  it  not  seem  to  imply  an  increase  of 
power,  rather  than  a  diminution  of  force?  What  would  seem  to 
be  the  natural  consequence  of  a  weakened  state  of  the  uterine 
vessels,  or  any  other  vessels  in  a  state  of  weakness?  Certainly, 
that  they  must  perform  a  lesser,  instead  of  a  greater  duty. 

If  the  vessels  of  a  part  are  really  weakened,  it  seems  to  follow, 
that  less  exertion  can  be  expected  from  them  than  when  in  a  state 
of  health  and  vigour;  yet,  agreeably  to  this  doctrine,  they  perform 
more  than  in  that  state  of  vigour,  because  they  are  weaker,  and 
(as  we  should  think)  less  able  to  do  so.  It  would  also  appear,  that 
when  vessels  were  really  weakened,  they  would  be  less  able  to 
transmit  their  contents  ;  yet  more  is  poured  out  —  first,  in  the  form 
of  blood,  as  in  menorrhagia  ;  and  then  of  an  elaborated  fluid,  called 
fluor  albus  ;  for  elaborated  it  really  is  ;  yet  these  vessels  are  said 
to  be  weaker  than  in  a  state  of  health. 

But  would  it  not  seem  to  be  a  natural  effect,  if  the  vessels  of 
a  part  be  preternaturally  weak,  that  the  loss  of  several  ounces  of 
blood  immediately  from  them,  would  increase  this  weakness? 
Yet,  so  far  is  this  from  being  the  case,  agreeably  to  the  scheme 
of  Dr.  Cullen  and  many  others,  that  they  must  be  strengthened  ; 
since  the  fluid  they  evacuate  is  more  elaborated,  and  in  greater 
quantity,  than  in  a  state  of  health.  Will  any  one  declare  the 
vessels  of  the  kidneys  to  be  in  a  state  of  weakness  in  diabetes, 
because  they  yield  quadruple  the  ordinary  quantity  of  urine  ?  Will 
any  one  say  that  the  salivary  glands  are  in  a  state  of  weakness, 
because  they  secrete  a  superabundant  quantity  of  saliva,  under 
the  action  of  mercury  ? 

But  Dr.  Cullen  does  not  stand  alone  in  this  assumption;  for 
most  of  the  writers  upon  the  subject  have  yielded  to  the  same 
erroneous  opinion;  thus,  Chambon,  Denman,  Leake,  Vigarous, 
Gardien,1  Capuron,  Burns,  &c.,  all  talk  of  debility,  either  local  or 
constitutional,  as  the  cause  of  leucorrhoea.  Even  Mr.  Clarke. 
who  has  written  so  ably  upon  several  of  the  complaints  of  females, 
joins  in  the  same  belief. 

Mr.  Hunter  says,  that  "  the  term  weakness  gives  us  no  idea  of 
a  disease:  and,  indeed,  there  is  none  that  can  be  annexed  to  the 
expression.  By  mechanical  weakness  is  understood  the  inability 
to  perform  some  action,  or  sustain  some  force.  By  animal  weak- 
ness the  same  thing  is  understood:  but  when  the  expression  is 
applied  to  the  animals  performing  an  uncommon  or  additional 
action,  I  do  not  understand  it."  Treatise,  art.  Gleet. 

"2d.  From  its  appearing  chiefly,  and  often  only  a  little  before, 
as  well  as  immediately  after,  the  flow  of  the  menses." 

This  will  certainly  prove  nothing  in  favour  of  the  position  of 

1  Gardien,  it  must  be  observed,  has  scarcely  done  more  than  given  a  literal  trans- 
lation of  a  great  part  of  Cullen's  chapter  on  this  subject. 

5 


66  LEUCORRH(EA. 

Dr.  Cullen;  for,  though  we  admit  it  to  be  a  fact,  in  many  instances, 
that  the  discharge  is  increased  "a  little  before"  the  appearance 
of  the  menses,  it  is  not  always  the  case  immediately  after  ;  though, 
if  it  were  allowed  to  be  precisely  as  stated  by  Dr.  Cullen,  it  would 
not  confirm  his  doctrine,  nor  militate  against  the  explanation  we 
shall  give  of  that  phenomenon. 

It  is  admitted  by  all,  be  their  theories  of  menstruation  what 
they  may,  that  there  is  more  blood  invited  to  the  uterus  and  its 
dependencies  at  the  time  the  menses  are  about-  to  be  secreted, 
during  their  secretion,  and  immediately  after,  than  at  any  other . 
period,  except  when  this  organ  is  in  a  state  of  gravidity ;  it  will 
not  then  be  disputed,  that  this  increase  of  blood  is  intended  to 
furnish  the  menstruous  fluid ;  and  that  this  process  is  effected  by 
an  increase  of  action  in  the  vessels  of  the  uterus.  Now,  when  the 
vessels  of  the  uterus  and  vagina  are  more  abundantly  supplied 
with  blood,  it  is  more  than  probable  that  the  vessels  on  the  se- 
creting surfaces  of  these  parts  will  be  urged  from  this  stimulus  to 
greater  duty ;  and  consequently,  made  to  furnish  a  greater  supply 
of  the  fluid  they  are  in  the  habit  of  eliminating;  and,  hence,  the 
appearance  and  sometimes  increase  of  this  discharge.1  This  will 
therefore  account  for  the  fluid  being  more  abundant  just  before 
the  menses  appear ;  and  a  continuation  of  this  action,  (which  it  is 
nowise  doubtful  sometimes  exists,)  after  the  menses  have  been 
poured  out,  will  account  for  the  fluor  albus,  or  an  increase  of  dis- 
charge at  this  time.  For  it  may  again  be  proper  to  observe,  that 
the  engorged  state  of  the  vessels  of  the  vagina  during  pregnancy, 
produces  very  often  the  same  consequences ;  when  it  is  every  way 
certain,  that  this  discharge  cannot  be  furnished  "from  the  same 
vessels  which,  in  their  natural  state,  pour  out  the  menses." 

"  3d.  From  the  flow  of  the  menses  being  diminished,  in  propor- 
tion as  the  leucorrhoea  is  increased." 

Were  this  statement  a  fact,  it  would  not  interfere  in  the  least 
with  an  explanation  that  is  easily  and  well  ascertained  to  have 
this  effect  in  other  portions  of  the  body ;  namely,  that  the  conges- 
tive state  of  the  uterine  vessels,  so  essential  to  the  production  of 
the  menses,  are  relieved,  to  a  certain  extent,  by  the  continual 
drain  of  fluids  from  the  vagina.2  But  the  assumption  of  Dr. 
Cullen,  that  the  menses  diminish  in  proportion  to  the  increase  of 

'  Dr.  Cullen  himself  tells  us,  par.  988,  that "  though  the  leucorrhcea  depends  chiefly 
upon  the  laxity  mentioned,  (of  the  extreme  vessels  of  the  uterus,)  it  may  have 
proceeded  from  irritation  inducing  that  laxity,  and  seems  to  be  always  increased  by 
any  irritations  applied  to  the  uterus." 

*  Every  body  is  familiar  with  the  influence  of  drains  of  every  kind  in  relieving 
local  inflammation  and  congestion.  It  is  upon  this  principle,  that  blisters,  issues, 
and  setons,  are  constantly  employed,  with  so  much  success,  in  cases  where  this 
kind  of  counter-irritation  is  required,  or  even  where  it  is  desirable  to  counteract 
the  waste  from  discharging  su.faces,  be  these  discharges  sanguineous,  serous,  or 
purulent,  or  wherever  situated. 


LEUCORRH<EA.  67 

leucorrhoea,  is  contradicted  by  all  observation ;  for  all  writers 
declare  that  those  women  who  are  subject  to  menorrhagia  are 
most  liable  to  leucorrhcea.  Indeed,  he  says  himself,  that  it  often 
follows  or  accompanies  this  complaint. 

"4th.  From  the  leucorrhoea  continuing  after  the  menses  have 
entirely  ceased,  and  with  some  appearance  of  its  observing  a 
periodical  recurrence." 

This  statement  appears  to  us  to  be  conclusive  against  the  Doc- 
tor's argument;  for  if  the  same  vessels  furnished  both  the  men- 
strual and  leucorrhceal  discharge  in  the  early  part  of  life,  why 
should  these  vessels  be  unable  to  furnish  the  menses  in  the  latter 
part,  if  they  are  still  as  capable  as  formerly,  of  throwing  out  the 
discharge  of  fluor  albus  ?  It  must,  however,  be  remembered,  that 
leucorrhoea  is  by  no  means  so  common  after  the  cessation  of  the 
menses  as  before,  unless  there  is  some  organic  lesion  of  either 
the  uterus  or  vagina ;  and  when  this  is  the  case,  every  body  seems 
to  agree,  that  this  discharge  should  not  be  considered  as  a  genuine 
leucorrhoea. 

U5th.  From  the  leucorrhoea  being  accompanied  with  the  effects 
of  the  menorrhagia."1 

This  is  a  most  hasty  and  ill-founded  conclusion :  for  hemorrhoids, 
a  diseased  liver,  or  diseased  viscera  of  any  kind;  a  sore  leg,  &c. 
&c.,  will  have,  after  a  certain  time,  almost  every  symptom  described 
by  Dr.  Cullen  as  belonging  to  menorrhagiS. 

"  6th.  From  the  discharge  having  been  neither  preceded  by,  nor 
accompanied  with,  symptoms  of  any  topical  affections  of  the 
uterus." 

Now,  if  this  prove  any  thing,  it  should  be  the  reverse  of  what 
Dr.  Cullen  seems  to  insist  on,  namely,  that  leucorrhoea  "  pro- 
ceeds from  the  same  vessels,  which,  in  their  natural  state,  pour 
out  the  menses;"  for  how  a  want  of  evidence  of  "topical  affec- 
tions of  the  uterus,"  should  prove  the  identity  of  the  vessels  which 
furnish  at  one  time  the  menses,  at  another  the  matter  of  fluor 
albus,  is  really  beyond  our  comprehension.  .  His  seventh  argument 
we  shall  not  notice,  as  it  has  not  the  slightest  bearing  upon  the 
subject. 

1  "When,  in  consequence  of  the  circumstances,  and  the  repetition  of  them,  (the 
too  frequent,  and  too  abundant  menses,)  the  face  becomes  pale;  the  pulse  grows 
weak;  an  unusual  debility  is  felt  in  exercise;  when,  also,  the  back  becomes  pained 
from  any  continuance  in  an  erect  posture;  when  the  extremities  become  frequently 
cold;  and  when,  in  the  evening,  the  feet  appear  affected  with  cEdematous  swellings; 
we  may,  from  these  symptoms,  certainly  conclude,  that  ihe  flow  of  the  menses  has 
been  immoderate,  and  has  already  induced  a  dangerous  state  of  debility."  First 
Lines,  par.  973. 

"The  debility  thus  induced  does  often  discover  itself  also  by  the  affections  of 
the  stomach,  anorexia,  and  other  symptoms  of  dyspepsia;  by  a  palpitation  of  the 
heart,  and  frequent  faintness;  by  a  weakness  of  mind  liable  to  strong  emotions  from 
slight  causes,  especially  when  sud.lenly  presented."  Par.  973. 


68  LEUCORRHOEA. 

I  have  never  been  perfectly  satisfied,  but  in  three  or  four  in- 
stances, of  the  very  many  cases  of  leucorrhoca  which  have  been 
under  my  care,  that  the  discharge  in  question  proceeded  from 
the  cavity  of  the  uterus.1  In  all  these  cases,  the  following  pecu- 
liarities were  present.  1st.  During  the  night,  there  would  be  no 
discharge  whatever;  but  upon  rising,  there  would  be  a  very  abun- 
dant one,  of  a  glairy,  tenacious  substance;  sometimes  mixed  with 
some  of  a  purulent  appearance.2  2d.  That  during  the  day,  when 
it  did  escape,  it  was  always  suddenly,  and  accompanied  by  a 
sensation  of  effort  within.  3d.  That  when  a  piece  of  sponge  was 
introduced  into  the  vagina  at  night,  with  a  view  of  determining 
the  point,  it  was  never  found  filled  with  the  kind  of  matter  that 
would  very  quickly  issue  when  this  was  removed.  4th.  All  these 
cases  I  found  to  be  incurable,  though  capable  of  some  relief.  5th. 
All  these  women  were  barren. 

These  considerations  make  us  believe,  that  fluor  albus  has  its 
seat,  for  the  most  part,  in  the  vagina.  We  believe,  farther,  that 
it  is  almost  always  local;  but  from  the  excess  of  quantity,  or 
peculiarity  of  quality,  the  system  frequently  becomes  involved. 
Mr.  Clarke  says,  "  The  constitution  is  rarely  affected  in  this  dis- 
ease ;  the  action  of  the  heart  and  arteries  is  not  increased,  and  the 
functions  of  health  are  seldom  interrupted."  Vol.  ii.  p.  14.  This 
statement  is  in  entire  conformity  with  my  own  experience,  as  far 
as  regards  the  first,  ana  sometimes  the  second  stage,  that  I  make 
of  this  complaint,  as  I  shall  observe  presently ;  but  in  the  third, 
the  system  suffers,  in  a  greater  or  less  degree,-  the  same  altera- 
tions which  any  long-continued  irritation  or  excessive  discharges 
of  any  kind  produce  upon  it.  The  quantity  of  the  discharge  will 
almost  necessarily  determine  in  what  degree  the  system  at  large 
suffers,  or  at  least  when  this  complaint  is  idiopathic;  and  such  it 
almost  always  is.  But  when  this  discharge  is  purely  sympathetic, 
the  disease,  of  which  it  may  be  merely  an  anomalous  symptom, 
must,  in  great  measure,  determine  the  degree  of  injury  the  system 
may  sustain — as  in  cases  of  ascarides;  hemorrhoids;  prolapsus 

1  It  will  be  seen,  that  I  am  not  disposed  to  deny  altogether,  that  leucorrhcea  may 
occasionally  have  its  seat  in  the  uterus;  I  only  wish  to  be  understood,  that  I  do  not 
by  any  means  think  it  as  common  as  authors  would  lead  us  to  suppose.  Morgagni 
tells  us  expressly,  he  pressed  from  the  orifice  of  the  uterus  a  matter  resembling 
that  which  the  woman  was  wont  to  render  from  the  vagina  while  living.  But  he 
also  tells  us  of  an  instance,  in  which  the  matter  was  confined  to  the  vagina  alone; 
and  which,  he  expressly  states,  had  no  higher  origin  than  the  vagina.  Epist.  xvi. 
art  47. 

""The  uterus  is  lined  throughout  with  a  mucous  membrane;"  the  "  secretion 
from  this  membrane  is  permanent ;"  the  mucus  secreted  by  this  membrane,  "  re- 
sembles, in  consistence  and  appearance,  the  uncoagulated  white  of  an  egg,  and  does 
not  differ  from  mucus  in  other  parts  of  the  body."(<z) 

(a)  H  According  10  the  experiments  of  Mr.  William  Brande,  mucus  consi-ts  of  albumen  and  soda. ' 
—Clarke  on  Diaeirei  of  Female*,  vol  i.  p.  15.— An.  Ed. 


LEUCORRHCEA.  b« 

uteri,  &c.  &c.,  though  it  will  be  evident,  that  the  two  diseases  will 
deteriorate  the  constitution  faster,  than  either  would  alone. 

But  whether  this  discharge  proceed  from  the  uterus  or  vagina, 
or  both,  it  is  evidently  maintained  by  some  local,  or,  perhaps, 
specific  irritation ;  but  of  the  nature  of  which  I  am  not  prepared 
to  decide;  but  its  influence  is  evidently  spent  upon  the  vaginal 
lacuna?,  or  glands,  which,  in  a  state  of  health,  furnish  the  mois- 
ture so  important  to  this  part.  In  my  present  consideration  of 
this,  subject,  I  would  wish  to  be  understood,  not  to  include  the 
discharge,  which  is  symptomatic  of  some  derangement  of  the 
proper  substance  of  the  uterus,  or  that  which  always  accompanies 
a  prolapsus  of  this  organ :  these  will  be  treated  of  under  their 
respective  heads. 

The  idiopathic  forms  of  this  disease  may  be  divided  into  three 
stages ;  each  of  which  requires  a  little  difference  of  management ; 
in  the  first,  or  most  simple  form,  the  matter  discharged  is  glairy 
and  transparent;  or  resembling  a  thin  starch  made  by  boiling; 
this,  from  its  tenacity,  very  often  accumulates  in  considerable 
quantity  within  the  vagina,  and  is  suddenly  discharged,  from  time 
to  time,  either  by  its  own  weight,  or  from  some  sudden  exertion 
of  the  woman;  especially  upon  stooping,  or  lifting  a  weight — 
this  never  becomes  acrid,  unless  there  is  the  most  reprehensible 
neglect  of  cleanliness;  nor,  so  far  as  I  have  observed,  is  the  san- 
guiferous  system  generally  implicated,  though  it  may  take  place 
occasionally  in  women  constitutionally  plethoric,  or  very  feeble, 
and  where  it  is  easy  to  suppose  it  might  be  called  into  action  by 
a  trifling  irritation.  But  the  irritation,  or  inflammation,  which 
provokes  this  increase  of  discharge  from  these  parts,  is  in  common 
BO  local,  and  so  mild,  as  to  exert  no  influence  whatever  upon  the 
general  system.  But  this  is  not  always  so,  as  we  have  just  admitted ; 
especially  if  the  system  be  easily  brought  into  sympathy  from  local 
irritations:  in  this  case,  as  we  shall  observe  presently,  the  sangui- 
ferous  system  will  be  found  disturbed. 

It  is  probable  that  this  peculiar  mucus  may  be  furnished  by 
the  neck  of  the  uterus  alone:  and,  therefore,  this  first  stage  may 
consist  of  the  inflammation  of  this  part,  since,  agreeably  to  Mr. 
Clarke,  this  part  yields  a  fluid  differing,  at  least  in  sensible  quali- 
ties, from  that  found  upon  the  surface  of  the  vagina.  He  informs 
us,  that  "  the  mucus  secreted  by  the  glands  of  the  neck  of  the 
uterus  contains  less  water  than  any  other  mucus  in  the  body, 
approaching  nearer  to  the  nature  of  a  solid  than  that  of  a  fluid 
body;  it  is  semi-transparent,  and  possessed  of  great  tenacity;  it 
adheres  to  the  fingers  like  bird-lime."  "These  glands,  (of  the 
neck  of  the  uterus,)  in  a  state  of  health,  perform  the  office  of 
secretion  in  pregnancy  only;  or  if,  at  any  other  time,  the  matter 
secreted  is  of  a  very  different  kind,  so  resembling  common  mucus, 
as  not  to  be  distinguished  from  it."  Clarke,  vol.  i.  p.  17. 


70  LEUCORRHCEA. 

In  the  stage  now  under  consideration,1  (namely,  the  first,)  wo 
sometimes  find  the  discharge  vary  from  time  to  time,  without  the 
woman  being  able  to  account  for  the  difference  of  appearance : 
but  these  changes  must  have  causes,  however  occult  they  may 
be :  I  think  I  have  almost  always  traced  them  to  some  impru- 
dence on  the  part  of  the  patient ;  for,  though  the  complaint  is 
confessedly  a  troublesome  one,  it  does  not  always  challenge  the 
attention  of  those  labouring  under  it,  sufficiently  to  secure  their 
best  aid  in  getting  well  of  it — hence,  errors  in  diet  will  be  com- 
mitted; costiveness  permitted  for  a  long  time  together;  cleanli- 
ness will  oftentimes  be  neglected;  over  exertions  will  be  made,  or 
a  series  of  fatiguing  duties  will  be  submitted  to,  all  of  which  will 
have  more  or  less  influence  upon  the  parts  concerned  in  the  pro- 
duction of  this  discharge. 

During  the  attempt  to  cure  this  complaint,  every  thing  capable 
of  increasing  it  should  be  carefully  avoided ;  and  the  female  will 
find  her  best  interests  involved  in  the  most  strict  conformity  to 
the  physician's  directions  for  this  purpose ;  while  on  the  other 
hand,  the  physician  will  find  it  best  to  be  very  particular  in  his 
inquiries  respecting  the  quantity  and  the  appearance  of  the  dis- 
charge, as  he  can  only  prescribe  with  certainty  and  effect  while 
his  attention  is  directed  to  these  points.  It  is  but  by  the  uniform, 
or  varying  appearance  of  the  discharge,  that  he  can  determine 
the  actual  state  of  this  disease;  whether  his  remedies  are  acting 
according  to  his  intentions,  or  that  he  can  be  led  to  suspect  a  want 
of  fidelity  to  her  own  health,  on  the  part  of  the  patient. 

It  is  possible  that  the  inflammation,  (or  perhaps  only  a  form  of 
it,)  which  gives  rise  to  the  first  stage  of  fluor  albus,  may  be  con- 
fined to  the  neck  of  the  uterus  alone  for  a  considerable  length 
of  time;  but  if  it  be  suffered  to  remain  unheeded,  it  will  sooner 
or  later,  and  in  different  degrees,  involve  the  surface  of  the  va- 
gina. Or  the  inflammation  may  suffer  various  degrees  of  inten- 

*  It  has  been  thought  by  some,  that  the  difference  in  the  appearance  of  the  dis- 
charges in  leucorrheea,  and  from  which  we  derive  the  stages  into  which  we  have 
divided  this  complaint,  did  not  indicate  the  degree  or  the  inveteracy  of  it;  but 
rather  determined  the  part  of  the  genital  system  which  furnished  it,  or  the  specific 
nature  of  the  inflammation  that  produced  the  matter  discharged.  Thus,  Chambon* 
thinks,  when  the  discharge  is  green,  that  it  proceeds  from  "une  disposition  pro- 
chaine  au  scorbut,  qui  ont  un  vice  dartreux  ancien,  ou  scrophuleux  ou  enSsipela- 
teux."  But  the  various  shades  of  colour  which  this  discharge  assumes  only  manifest 
the  intensity  of  the  irritation.  Notwithstanding  we  have  divided  the  complaint  into 
three  stages,  because,  in  general,  when  left  to  itself,  it  goes  regularly  through  them, 
yet  the  force  of  the  irritating  cause  may  be  so  very  great,  as  to  make  the  first  dis- 
charge observed  by  the  woman  of  the  quality  of  the  third  stage.  We  have  seen 
this  in  a  number  of  instances;  but  we  think  it  has  almost  always  happened  after 
some  severe  mechanical  injury  done  to  the  vagina :  hence  it  is  more  frequent  after 
severe  labours. 

»  Vol.  if.  p.  l!2. 


LEUCOKRHCEA.  71 

sity,  while  its  location  is  confined  to  its  original  seat,  namely,  the 
neck  of  the  uterus. 

It  may  look  like  a  gratuitous  assumption  to  those  who  make 
leucorrhoea  consist  solely  in  a  "weakness"  of  the  uterus  and 
vagina,  to  declare,  that  in  the  first  stage  of  this  complaint,  an 
inflammation  really  exists  in  the  neck  of  this  organ.  But  such  is 
the  fact;  at  least  so  far  as  certain  phenomena,  without  the  aid  of 
ocular  demonstration,  will  warrant  such  a  conclusion.  In  the 
first  place,  it  seems  that  the  quality  of  the  natural  secretion  of  this 
part  is  altered;1  for  from  being  of  extreme  tenacity  and  conside- 
rable density,  it  becomes  less  tenacious,  transparent,  and  thinner ; 
in  the  second,  that  still  farther  changes  can  be  imposed  upon  the 
discharge  by  such  causes  as  are  calculated  to  augment  the  gene- 
ral action  of  the  system,  or  to  increase  local  determination;2  in 
the  third  place,  when  this  part  is  touched,  and  even  this  not 
rudely,  pain  is  invariably  produced;3  in  the  fourth  place,  that 
parts  both  adjacent  and  remote  are  frequently  brought  into  sym- 
pathy from  this  condition  of  the  neck  of  the  uterus  ;4  and  in  the 
fifth  place,  the  remedies  found  most  effectual  for  the  removal  of 
the  complaint,  are  opposite  in  quality  to  those  which  would  be 
employed,  did  the  discharge  in  fluor  albus  depend  upon  weak- 
ness.5 

•  *>'<*•  '•:•'•.--  ;t,'.\'i'r:i:'  '}••  1;::I-I    .'         •  ~'T     \*r  r:--.i\--'  •<••'  :.V-  •?•'  .[-,.  t  v 

1  It  has  just  been  declared  above,  that  the  natural  secretion  of  the  neck  of  the 
uterus,  was  '•  semi-transparent,  and  of  great  tenacity;  adhering  to  the  ringers  like 
bird-lime."  It  seems,  then,  the  first  degree  of  morbid  change  alters  the  secretion 
to  one  that  "  is  glairy  and  transparent,  or  resembling  a  thin  starch  made  by  boiling." 
A  greater  degree  makes  it  "  opaque,  and  of  a  perfectly  white  colour;  and  it  resem- 
bles, in  consistence,  a  mixture  of  starch  and  water  made  without  htat ;  or  thin  cream  ; 
it  is  easily  washed  from  the  finger  after  an  examination,  and  it  is  capable  of  being 
diffused  through  water,  rendering  it  turbid." — Clarke  on  the  Diseases  of  Females, 
vol.  ii.  p.  5. 

"  An  attack  of  fever,  high  living,  excess  of  venery,  exercise  carried  to  fatigue, 
intemperance  in  drinking,  over  stimulating  injections,  excessive  costiveness,  an 
attack  of  hemorrhoids,  and  approach  of  the  menstrual  period,  will  each  occasionally 
increase  the  irritation  at  the  neck  of  the  uterus. 

*  "  A  morbid  state  of  the  glands  in  the  cervix  of  the  uterus,  probably  gives  rise 
to  this  discharge;  at  least,  the  cases  in  which  it  comes  away,  are  those  in  which 
the  symptoms  are  referred  to  this  part,  and  when  pressure  is  made  upon  this  part, 
under  such  circumstances,  the  woman  complains  of  considerable  pain." — Clarke  on 
the  Diseases  of  Females,  vol.  i.  p.  37. 

4  A  pain  in  the  small  of  the  back  is  almost  sure  to  attend  a  morbid  condition 
of  the  cervix  uteri,  as  in  cancers,  ulcers,  lesions  from  rude  delivery,  or  the  incau- 
tious use  of  instruments.  The  bladder  is  frequently  urged  to  discharge  itself,  and 
a  numbness  is  felt  down  the  thighs. 

•  Mr.  Clarke  makes  two  species  of  "the  transparent  mucous  discharge;"  the 
first  is  that  which  originates  from,  and  is  accompanied  by,  increased   action  of 
the  vessels  of  the  parts.     The  second,  that  which  originates  in  debility;  in  which 
latter  case,  the  former  may  terminate. — Clarke  on  the  Diseases  of  Females,  vol.  i. 
p.  300. 

It  will  be  seen,  that  we  acknowledge  but  the  first  of  these  as  an  original  disease; 
and  that  when  the  inflammatory  stage  is  subdued,  and  the  discharge  continues,  it 
then  becomes  "the  leucorrhoea  of  habit;"  which  almost  always  takes  place  before 
the  cure  is  completed. 


LEUCOKRH<EA. 


Method  of  Cure  of  the  first  Stage  of  Leucorrhosa. 

The  cure  should  be  commenced  by  directing  the  parts  to  be 
regularly  washed  with  warm  water,  three  or  four  times  a  day  — 
if  the  patient  be  plethoric,  I  cause  her  to  be  well  purged  ;  confine 
her  to  milk  and  vegetable  diet  ;  and  sometimes  order  her  to  lose 
blood1  —  when  the  pulse  is  sufficiently  reduced  by  these  means, 
or  if  the  pulse  be  in  a  proper  condition  without  them,  I  exhibit 
the  tincture  of  cantharides  ;  of  this  I  direct  thirty  drops  every 
morning,  noon,  and  evening,  in  a  little  sugar  and  water  ;  increasing 
the  dose  every  third  day,  five  drops  at  a  time,  until  strangury2 
is  produced,  unless  the  disease  is  arrested,  which  is  not  unfre- 
quently  the  case  before  this  symptom  appears.  Should  the  com- 
plaint withstand  the  first  strangury,  I  am  not  discouraged,  but 
recommence  the  tincture  at  the  original  dose  of  thirty  drops,  and 
increase  it  as  before,  until  a  difficulty  in  making  water  is  again 
experienced  —  it  rarely,  however,  withstands  the  second  irritation 
of  the  bladder. 

Astringent  injections  are  employed  as  soon  as  a  change  is  ob- 
served in  the  discharge  ;  that  is,  by  its  becoming  thinner  and 
more  abundant,  but  never  until  then,  should  this  require  three  or 
four  stranguries  to  effect  it.  The  best  kind  of  astringent  injec- 
tions are  the  acetate  of  zinc,  in  the  proportion  of  five  or  six 
grains  to  the  ounce  of  water,  or  the  sulphate  of  copper  in  solu- 
tion, in  the  proportion  of  a  scruple  to  half  a  drachm  to  eight 
ounces  of  water;  either  of  these  may  be  employed  three  times 
a  day,  taking  care  to  wash  out  the  vagina  with  soap  and  water 
previously. 

During  the  treatment  of  leucorrhoea,  too  little  attention  is  com- 
monly paid  to  cleanliness  ;  if  this  necessary  act  be  neglected,  as 
reprehensible  as  it  generally  is,  very  little  good  will  be  derived 
from  the  prosecution  of  the  best  plan  of  cure.  On  this  account, 
we  importunately  urge  the  compliance  with  the  direction  of  fre- 
quent washings  with  warm  water,  as  well  as  the  cleansing  of  the 
vagina,  by  throwing  up  it  several  syringes-full  of  warm  soap 

1  It  may  be  well  to  observe,  that  a  strict  antiphlogistic  plan  is  constantly  pursued 
during  the  cure  of  either  stage  of  this  complaint,  until  we  are  assured  the  discharge 
is  maintained  by  habit. 

*  I  always  direct  my  patient  to  desist  from  the  use  of  the  tincture,  as  soon  as  she 
feels  the  approach  of  strangury,  and  not  to  resume  it  until  all  uneasiness  disappears. 
If  the  strangury  be  severe,  the  free  use  of  flax-seed  tea,  barley  water,  or  gum  Arabic 
water  is  directed  —  to  take  five  and  thirty  drops  of  laudanum,  and  go  to  bed.  Should 
this  not  succeed,  an  enema  of  a  gill  of  thin  starch,  a  tea-spoonful  of  laudanum,  and 
thirty  grains  of  finely  powdered  camphor  must  be  given  —  so  far  as  I  recollect,  this 
enema  his  never  failed.  It  may  also  be  proper  to  mention,  that  the  tincture  of 
cantharides  I  employ  is  fifty  per  cent,  stronger  than  the  ordinary  tincture  of  the 
shops  ;  or,  in  other  words,  where  they  use  two  drachms,  I  use  three  for  making  the 
tincture. 


LEUCORKHCEA.  73 

suds ;  especially  before  the  injections,  intended  immediately  for  the 
complaint,  are  administered.  By  this  plan,  two  important  objects 
are  gained;  first,  the  matter  occupying  the  vagina  is  removed, 
frequently;  and  thus  is  prevented  all  the  injuries  that  might  arise 
from  its  stagnation  ;  secondly,  the  surface  of  the  vagina  is  deterged 
by  this  means,  and  the  medicated  injections  have  full  opportunity 
to  exert  their  influence  upon  the  inflamed  surface  that  furnishes 
the  discharge. 

It  is  also  difficult  to  secure  compliance,  as  regards  diet  and 
drinks — the  patient,  her  friends,  and,  perhaps,  the  physician,  de- 
clare the  disease  to  be  a  disease  of  "weakness;"  one  which  re- 
quires tonic  and  stimulating  remedies  for  its  cure  ;  hence,  the  most 
stimulating  and  nutritious  articles  of  diet  are  generally  had  re- 
course to,  to  the  manifest  injury  of  the  patient. 

We  have  never  witnessed  an  instance  of  the  first  stage  of  this 
complaint,  attended  by  such  a  degree  of  debility  as  would  require 
either  tonics  or  animal  diet  for  its  relief.  Mr.  Clarke  has  fallen 
into  an  error  upon  this  subject,  at  which  we  are  not  a  little  sur- 
prised ;  especially,  as  his  general  view  of  the  disease  is  correct  and 
well  founded. 

He  says,  "  The  food  should  be  of  the  lightest  kind,  such  as 
animal  broths  and  jellies;  vegetable  jellies,  bread  properly  fer- 
mented and  well  baked."1  This  selection  of  food  seems  in  direct 
variance  with  his  opinions  of  the  complaint,  for  he  has  declared 
the  neck  of  the  womb  to  be  in  a  state  of  inflammation ;  and  has 
also  said,  "that  if  this  disease  arises  from  inflammatory  action,  this 
must  be  removed  before  any  endeavour  to  restrain  it  is  employed ; 
for  as  the  discharge  during  its  continuance  lessens  the  disease 
which  occasioned  it,  it  should  not  be  checked  until  such  inflamma- 
tory action  is  diminished."2  Yet  he  advises  "animal  broths  and 
jellies"  during  the  inflammatory  stage  of  this  complaint;  than 
which  nothing  can  be  more  contradictory. 

He  appears,  however,  to  look  upon  the  modifications  of  animal 
substances  to  do  away  their  specific  nutritive  and  stimulating 
qualities ;  for  in  the  very  paragraph  in  which  he  advises  the  use 
of  "animal  broths  and  jellies,"  he  tells  us,  "it  will  be  better  that 
the  patient  should  not  eat  solid  animal  food  until  the  powers  of  the 
stomach  are,  in  some  degree,  restored."  Now,  it  is  very  well 
ascertained  that  the  stomach  will  almost  always  better  assimilate 
small  quantities  of  solid  animal  food,  than  the  preparations  he  has 
recommended.  But  "when  the  powers  of  the  digestive  organs 
become  more  vigorous,  recourse  may  be  had  to  animal  food;"  and 
this  is  not  all,  for  he  also  says,  "Wine,  either  pure  or  mixed 
with  water,  as  may  best  suit  the  palate  or  the  stomach,  may  be 
allowed  in  moderate  quantities."3  The  medical  treatment  con- 

1  Vol.  I.  p.  316.  »  Ibid.  p.  34.  f  Ibid.  p.  16. 


74  LEUCORRH<EA. 

sists  of  the  exhibition  of  the  various  tonics,  both  vegetable  and 
mineral.  We  are  not  acquainted  with  the  agency  that  a  difference 
of  climate,  constitution,  and  mode  of  life  may  have,  to  render  the 
above  plan  successful  in  the  part  of  the  world  in  which  Mr.  Clarke 
resides;  but  certain  it  is,  we  could  not  succeed  with  such  treatment 
in  this  country,  even  in  those  cases  where  debility  might  appear 
to  be  the  most  certain  of  the  causes  which  produced  the  disease 
in  question. 

It  is  true,  that  the  view  Mr.  Clarke  has  taken  of  this  complaint, 
in  the  instances  for  which  the  above  plan  is  recommended,  would 
certainly  justify  the  treatment  recommended,  were  it  a  true  one, 
namely,  that  it  is  a  disease  of  "weakness:"  but  this  character  of 
the  disease  is  the  debateable  point;  and  here  we  are  unfortu- 
nately at  issue — he  believes  in  the  existence  of  the  complaint  from 
"weakness;"  we  declare,  that  until  it  becomes  the  "leucorrhoea 
of  habit,"  local  inflammation  is  always  present;  and  that  with 
this  state  of  the  neck  of  the  uterus  the  system  at  large  sometimes 
sympathizes  so  much  as  to  require  strict  attention  to  be  paid  to 
its  condition  ;  and  that  this  condition  requires,  for  some  time,  de- 
pletion and  antiphlogistic  regimen.  But  notwithstanding  this,  we 
will  not  say  that  Mr.  Clarke  has  not  met  with  cases  to  justify  the 
mode  of  treatment  he  recommends ;  we  mean  merely  to  insist  that 
we  have  never  met  with  a  case,  where  the  antiphlogistic  plan  was 
not  necessary,  when  there  was  evidence  of  this  inflamed  condition 
of  the  neck  of  the  uterus. 

But  what  is  still  more  surprising,  Mr.  Clarke  declares  in  another 
part  of  his  work,1  that  "in  ordinary  cases,  the  most  successful 
mode  of  treatment  is  to  take  away  some  blood,  either  by  cupping 
or  by  leeches  applied  to  the  groin  or  to  the  back ;  and  it  may  be 
necessary  to  repeat  the  local  bleedings  several  times.  If  sympa- 
thetic fever  be  present,  it  will  be  prudent  to  open  a  large  vessel, 
but  this  is  seldom  necessary,  and  all  useful  purposes  are  answered 
by  local  blood-letting." 

It  may  not  be  thought  amiss  to  repeat,  that  where  there  is  evi- 
dence of  this  condition  of  the  neck  of  the  uterus,  it  must  be  met 
by  blood-letting,  purging,  and  low  diet.  It  must,  however,  be 
admitted  that  the  degree  of  inflammation  is  rarely  so  high  as  to 
require  a  repetition  of  blood  letting,  either  general  or  topical. 
The  low-seated  pain  at  the  very  bottom  of  the  back,  pain  within 
the  vagina  upon  sitting  down,  together  with  a  somewhat  severe 
irritation  about  the  neck  of  the  bladder,  with  frequent  desire  to 
make  water,  though  very  strongly  characterizing  the  disease  in  a 
certain  stage,  are  but  rarely  met  with. 

It  is  a  circumstance  worthy  of  remark,  and  one  every  way 
calculated  to  confirm  the  correctness  of  the  pathology  adopted 

1  Vol.  II.  p.  24. 


LEUCORRHCEA.  75 

of  this  complaint,  that  the  discharge  successively  alters  its  cha- 
racter as  the  disease  diminishes  by  the  successful  application  of 
the  remedial  means.  For  as  the  pain  and  inflammation  abate,  the 
discharge  becomes  thinner  and  more  transparent,  and  if  the  can- 
tharides  have  been  successful,  nothing  but  the  natural  discharge 
of  the  part  is  discovered  to  issue  from  the  vagina. 

In  this  stage  of  the  complaint,  medicated  injections  are  not  al- 
ways necessary ;  for  after  the  system  will  bear  with  profit  the 
tinctura  lyttse,  it  for  the  most  part  soon  puts  a  stop  to  the  dis- 
charge. Should  the  discharge,  however,  be  copious  and  obsti- 
nate, after  it  has  become  thinner,  it  is  best  to  aid  the  cure  by  in- 
jections, provided  it  is  not  a  young  girl  that  is  the  subject  of  the 
complaint;  or  should  the  discharge  resume  its  late  appearance, 
the  system  must  again  be  acted  upon  by  blood-letting,  or  a  few 
repetitions  of  smart  purging. 

Exercise  of  a  very  moderate  kind  may  be  indulged  in,  but  fatigue 
should  always  be  very  carefully  avoided;  passions  or  emotions  of 
the  mind  should  be  guarded  against,  and  venery  very  little  in- 
dulged in. 

In  the  second  stage,  the  matter  discharged  has  a  white,  yel- 
lowish, or  purulent  appearance'— it  is  usually  more  abundant 
lhan  in  the  first  stage;  and  is  constantly  leaving  the  vagina  by  a 
uniform  stillicidium.  If  proper  attention  be  not  paid  to  cleanli- 
ness, it  may  become  offensive,  or  may  even  excoriate — this  state 
is  almost  always  accompanied  with  pain  in  the  back,  hips,  and  in 
the  region  of  the  pubes ;  the  woman's  complexion  is  generally 
sallow ;  and  when  the  discharge  is  excessive,  she  becomes  sub- 
ject to  a  train  of  nervous  symptoms,  which  are  both  troublesome 
to  the  patient,  and  difficult  of  management  to  the  physician.  This 
stage  consists  of  an  extension  of  the  inflammation  with  which  the 
first  stage  commenced ;  it  has  now  spread  to  the  vagina,  the  sur- 
face of  which  at  this  time  principally  furnishes  the  fluid  that  is 
discharged.  The  character  of  the  fluor  is  also  changed;  it  is  now 
of  a  deep  white,  or  yellowish  colour,  resembling  thick  cream  that 
has  stood  some  time. 

The  system  is  almost  always  distinctly  involved  in  this  second 
stage;  for  if  the  pulse  be  carefully  examined,  it  will  be  found 
hard,  wiry,  and  irritated — in  this  stage,  as  in  the  former,  the 
most  scrupulous  attention  to  cleanliness  is  recommended — I  purge 
most  commonly;  confine  the  patient  to  a  vegetable  diet;  and 
sometimes  bleed — I  am  sure,  that  in  every  stage  of  fluor  albus, 
time  is  always  saved,  ae  well  as  a  material  point  gained,  by  a 
brisk  catharsis  in  the  commencement  of  the  curative  plan ;  it 
should  therefore  never  be  neglected.  When  the  pulse  is  in  a 
proper  state  to  bear  the  tincture  of  cantharides,  it  is  to  be  exhi- 
bited as  above  directed ;  subject  to  the  same  restrictions  and  dis- 


76  LEUCORRHCEA. 


tinctions,  but  with  this  difference,  tha|  we  may  commence  advan- 
tageously, in  proper  subjects,  with  injections ;  but  they  should  be 
of  the  sedative  kind ;  a  weak  solution  of  the  acetate  of  lead  is 
perhaps  the  best:1  this  may  be  used  several  times  a  day,  preceded 
by  the  soap  and  water,  as  just  mentioned. 

In  the  third  stage,  there  is  an  aggravation  of  all  the  symptoms 
of  the  second;  the  discharge  is  of  a  greenish  colour,  and  is  fre- 
quently tinged  with  blood.  I  consider  both  the  last  forms  but 
exalted  degrees  of  the  first ;  that  is,  the  inflammation  is  greater  in 
their  numerical  order;  in  the  last,  therefore,  we  have  more  to 
contend  with  than  in  the  second;  and  more  in  the  second  than  in 
the  first.  It  seems  that  this  complaint,  when  neglected,  is  apt  to 
run  spontaneously  through  all  these  changes,  and  is  truly  one  of 
the  diseases  which  rarely  cures  itself.  These  changes  are  more 
certain  and  strongly  marked  in  women  who  are  a  little  advanced 
in  life,  than  in  younger  subjects;  and  especially  with  those  who 
have  borne  many  children,  and  who  are  inattentive  to  cleanliness ; 
and  in  such,  it  is  also  more  difficult  to  remove. 

It  is  thought  by  many  that  there  is  a  risk  in  stopping  this  com- 
plaint too  suddenly;2  indeed,  almost  all  the  writers  upon  this  sub- 
ject may  be  considered  as  of  this  opinion.  Yet  our  experience 
goes  to  prove  that  its  effects  upon  the  constitution  are  such  as  to 
render  its  cure  a  most  desirable  thing ;  for  it  not  only  does  in- 
jury to  the  woman,  but  also  to  her  offspring.  The  latter,  indeed, 
are  seldom  other  than  puny,  and  not  unfrequently  die  in  early 
infancy.  But  it  is  not  very  strange,  that  the  notion  that  there  is 
danger  in  curing  leucorrhoea  should  exist,  since  it  is  commonly 
thought  to  be  critical  or  sympathetic.  From  an  experience  in 
many  hundred  cases,  we  have  never  known  the  slightest  incon- 
venience to  arise  from  the  cure  of  this  complaint;  nor  is  it  pro- 
bable that  any  can  arise,  however  inveterate  the  disease  may  have 
been ;  and  for  this  plain  reason — that  in  proportion  to  the  dura- 
tion of  the  disease,  will  be  the  difficulty  of  arresting  it ;  and, 
agreeably  to  our  own  experience,  this  is  effected  always  gradu- 
ally ;  for  it  requires  great  perseverance  to  produce  a  change  in 
the  quantity  discharged;  the  system  becomes,  in  consequence,  in 
every  respect  prepared  for  the  change.  So  much  is  this  the  case, 
that  we  have  never  seen  an  instance  of  the  sudden  stopping  of 
leucorrhoea  when  this  complaint  was  of  long  standing ;  and  in  re- 
cent cases,  nothing  is  to  be  apprehended  from  a  speedy  arrest  of 
the  complaint.  But  as  regards  the  cure,  the  same  general  direc- 
tions are  applicable  to  all  the  stages.  Nothing  can  compensate 

1  The  solution  of  the  sugar  of  lead  should  not  exceed  a  scruple  to  eight  ounces  of 
water. 

*  Mr.  Jewel  speaks  of  metastases  to  the  joints  in  this  complaint  from  having  this 
discharge  too  suddenly  stopped.  This  we  have  never  witnessed. 


LEUCORRHCEA.  77 

for  the  neglect  of  cleanliness — this  must,  therefore,  be  insisted  on  ; 
the  bowels  must  be  purged;  and  as  the  system  is  more  frequently 
and  extensively  implicated  in  this,  than  in  the  former  stages,  we 
are  oftener  obliged  to  bleed  and  to  enforce  a  strict  observance  of 
a  vegetable  and  milk  diet.  We  may,  as  in  the  second  stage, 
where  the  subject  will  permit,  commence '  with  the  injections  of 
a  weak  solution  of  the  acetate  of  lead;  then  perseveringly  em- 
ploy the  cantharides — in  using  it  in  this  stage,  I  depart  from  the 
method  just  recommended,  if  the  disease  be  of  long  standing,  by 
more  gradually  increasing  the  dose,  or  making  the  intervals  of 
increase  two  or  three  days  longer.  My  reason  for  this  is,  that 
the  system  may  not  too  suddenly  be  affected  by  it ;  for  I  have 
observed,  that  when  strangury  is  hastily  induced,  the  effects  are 
neither  so  satisfactory,  nor  so  permanent,  as  when  more  slowly 
brought  on — I  may,  however,  remark  in  general,  that  the  more 
susceptible  the  system  is  of  the  influence  of  this  medicine  in 
moderate  doses,  the  more  easily  the  cure  is  accomplished. 

In  this  stage,  as  on  the  other  occasions,  I  do  not  use  the  astrin- 
gent injections  until  the  sign  for  their  employment  shows  itself; 
that  is,  an  increase  and  thinning  of  the  discharge.1 

Even  the  first  injections  of  this  kind  should  be  rather  more 
feeble  than  those  formerly  directed;  but  the  strength  must  be 
increased  as  the  parts  become  more  accustomed  to  them.  I  go 
on  again  and  again,  to  renew  the  strangury,  should  the  first  not 
be  sufficient.  Nor  am  I  discouraged,  if  the  complaint  does  not 
yield  to  several :  for  I  am  very  rarely  disappointed  in  the  opera- 
tion of  this  medicine,  when  sufficiently  persevered  in. 

I  confess,  however,  that  I  have  occasionally  found  the  cantha- 
rides unsuccessful;  but  cannot  this  most  truly  be  said  of  every 
known  remedy?  I  have  now  and  then  succeeded  with  the  balsam 
copaiva,  after  the  other  has  been  fully  tried  without  advantage ; 
and  I  have  also  effected  cures  in  some  obstinate  cases,  by.  the  use 
of  alum  and  nitre — rfive  grains  of  alum,  and  tec  of  nitre,  given 
three  times  a  day,  have  proved  very  successful  after  other  reme- 
dies have  failed.2 

In  a  late  work,  (1830,)  on  the  subject  of  leucorrhoea,  by  Mr. 
Jewell,  the  solution  of  the  nitrate  of  silver,  applied  to  the  neck  of 
the  uterus  and  vagina,  by  means  of  a  piece  of  sponge,  canula,  or 
syringe,  is  highly  spoken  of.  He  commences  with  a  solution  of 
two  or  three  grains  to  the  ounce  of  water,  and  gradually  in- 

1  Dr.  Hunt,  as  quoted  by  Dr.  Churchill,  says  he  has  cured  leucorrhcea  by  giving 
two  grains  of  capsicum,  morning,  noon  and  evening. 

*  We  are  aware  that  this  is  an  unchemical  mixture  ;  but  at  the  same  time  WP 
must  observe  that  these  unchemical  compounds  have  furnished  us  with  some  of 
our  best  remedies;  witness  the  acetate  of  zinc  when  prepared  by  mixing  a  solu- 
tion of  acet.  plumb,  and  sulph.  of  zinc.  This  is  truly  an  unchemical  mixture, — 
but  every  body  that  has  tried  it  as  a  collyrium,  in  certiin  stages  of  ophthalmia, 
is  satisfied  with  it. 


78  LE  UCORRIKE  A. 

creases  it  to  four  or  five  grains,  as  the  parts  become  accustomed 
to  its  action.  It  is  to  be  used  three  times  a  day,  unless  it  produce 
too  much  pain — in  which  case  it  is  to  be  reduced  in  strength,  or 
wait  until  the  irritation  cease. 

In  the  use  of  this  remedy,  care  must  be  taken  to  guard  against 
its  stain,  which  is  indelible.  This  will  be  best  obviated  by  the 
patient  guarding  herself  as  if  she  were  labouring  under  a  cata- 
menial  period ;  or  by  wearing,  during  its  use,  black  muslin  or 
calico  shifts.  The  sponge  appears  to  be  the  least  exceptionable 
mode  of  using  this  solution ;  this  is  done  by  saturating  a  piece  of 
this  substance  of  sufficient  size  to  be  retained  after  being  well  im- 
bued, with  the  solution — this  is  to  be  renewed  three  times  a  day. 
Or  the  curved  pipe  syringe  may  be  employed  three  or  four  times 
a  day,  unless  it  irritates  too  much — a  sensation  of  warmth  after 
its  use  is  rather  to  be  coveted. 

He  appears  to  have  ill-founded  prejudices  against  the  employ- 
ment of  cantharides.  He  also  recommends  the  tincture  of  iodine 
in  small  doses;  but  he  has  not  produced  any  indisputable  evi- 
dence that  it  has  been  useful.  He  appears  to  have  adopted  all 
the  principles  and  opinions  contained  in  this  chapter,  and  though 
he  makes  respectful  mention  of  the  author,  he  gives  him  no  credit 
for  his  opinions  upon  this  disease,  though  all  his  distinctions,  and 
plans  of  cure,  are  identical  with  those  contained  in  this  chapter. 

Mr.  Graham,  recommends  the  sulphate  of  zinc  in  this  disease 
— three  grains  of  the  sulphate  made  up  with  common  turpentine, 
three  times  a  day,  the  dose  to  be  increased  if  necessary.  Edinb. 
Med.  and  Surg.  Journ.  vol.  26. 

The  discharge  which  attends  the  prolapsus  uteri  is  owing  al- 
together, or  at  least  in  great  part,  to  the  mechanical  irritation  the 
surface  of  the  vagina  suffers  from  this  displaced  organ,  and  does 
not  come  under  our  present  consideration. 

The  leucorrhoea  of  habit  is  sometimes  more  obstinate  than 
any  other  form  of  this  complaint ;  especially  if  it  be  of  very  long 
standing,  and  in  persons  beyond  the  middle  period  of  life,  and 
who  are  inattentive  to  cleanliness.  It  will,  however,  yield,  for 
the  most  part,  to  the  remedies  already  mentioned,  if  sufficiently 
persevered  in ;  though  it  may  require  the  exciting  of  strangury 
rather  oftener.  I  have,  in  a  few  instances  of  this  kind,  used  an 
injection  made  of  two  grains  of  corrosive  sublimate  to  an  ounce 
of  water,  with  great  advantage.  It  should  be  used  but  once  a 
day,  for  the  first  two  or  three  days ;  then  twice  a  day  for  an  equal 
period;  and  then  three  times  a  day,  until  heat  or  other  signs  of 
irritation  be  perceived,  unless  it  has  been  previously  excited. 
This  irritation  must  be  kept  up  for  a  week  or  ten  days;  it  may 
then  be  followed  by  the  saturnine  injections.1 

1  The  secale  cornutum  is  recommended  with  great  confidence  in  leucorrhcea, 
and  also  in  gonorrhoea,  both  by  Dr.  Negri  and  Dr.  Ryan.  About  five  grains  three 


HISTORY    OF    MENSTRUATION.  79 

There  is  a  discharge  of  purulent  matter  that  has  been  consi- 
dered as  a  species  of  leucorrhoea.  It  generally  begins  with  pain 
about  the  region  of  one  of  the  ovaria,  and  will  continue  for  two, 
three,  or  four  days ;  the  abscess  then  discharges  (for  such  it  is,) 
and  gives  immediate  relief;  the  patient  will  continue  easy  until 
there  is  a  fresh  accumulation  of  pus  ;  this  takes  place,  pretty  re- 
gularly, every  three  or  four  weeks,  then  goes  through  the  same 
process  of  ulceration  and  discharge.  I  have  never  found  this 
complaint  obedient  to  medicine ;  I  have  used  an  injection  of  the 
nitrate  of  silver,  three  grains  to  the  ounce  of  water,  which  would 
moderate  this  discharge,  but  never  subdue  it;  it  sometimes  cures 
itself.  Dr.  Churchill  mentions  a  disease  very  similar  to  this,  which 
he  and  some  others  call,  "  abscess  of  the  uterus,  ovary,"  &c.,  &c., 
and  for  which  he  says,  (after  the  acute  symptoms  have  passed 
away,)  he  applies  a  blister  to  the  sacrum,  once  or  twice,  if  neces- 
sary. This  produces  an  immediate  diminution  of  the  discharge  and 
a  mitigation  of  suffering ;  but  he  says  nothing  of  a  cure. 

Leucorrhoea  proceeding  from  hemorrhoids,  I  believe,  will  ad- 
mit of  no  relief,  until  the  latter  complaint  be  removed.  The  same 
may  be  said  of  .the  leucorrhoea  arising  from  ascarides;  this  condi- 
tion of  the  vagina,  however,  is  chiefly  confined  to  children. 


CHAPTER  V.-SECT.  I. 

OF  THE  HISTORY  OF  MENSTRUATION. 

THE  diseases  connected  with  menstruation  are  so  important,  that 
I  have  thought  it  best  to  premise  them  with  a  general  history  of 
this  process,  that  the  deviations  from  health  should  be  seen  in 
stronger  contrast,  as  well  as  better  understood. 

The  menstrual  discharge  may,  with  much  propriety,  be  con- 
sidered as  peculiar  to  the  human  female;  if  there  be  exceptions 
to  this  rule,  they  are  few,  and  but  ill  ascertained.1  We  are  told 
that  the  female  of  a  certain  species  of  monkey  is  liable  to  it ;  but, 
perhaps,  in  no  other  way  than  the  bitch,  the  cow,  the  mare,  the 
female  elephant,  &c.,  are  said  to  be;  for  these,  in  the  time  of 
heat,  have  sometimes  a  sanguineous  discharge  from  the  vagina. 
But  this  must  not  be  considered  as  a  genuine  menstrual  evacua- 

times  a  day,  is  the  average  dose  in  these  cases;  they  recommend  its  suspension,  if 
it  excite  much  pain.  Of  its  utility  in  such  cases  we  can  say  nothing  from  our  own 
experience.  See  London  Med.  Journ.  for  I8:i4. 

1  "  De  to'us  les  etres  vivan?,  la  femwe  seu!«»  ftprouve  pJriodiquement  une  Eva- 
cuation sanguine  naturelle,  et  independante  d'aucune  alteration  pathologique." — 
Frank. 


80  HISTORY    OF    MENSTRUATION. 

tion,  as  it  proceeds  merely  from  the  rupture  or  abrasion  of  some 
small  vessel,  during  the  excessive  engorgement  that  is  wont  to 
take  place  in  the  vaginae  of  these  animals  at  such  times.  Besides, 
no  moral  end  could  be  answered  in  the  brute,  as  in  the  human 
female,  by  such  a  discharge. 

Indeed  some  would  deny  the  menstrual  discharge  to  be  an  ori- 
ginal function,  even  in  the  human  female,  as  Roussel,  and  after 
him  Emmet ;  that  this  evacuation  is  the  result  of  the  social  condi- 
tion of  man,  and  not  the  consequence  of  organization.  Roussel 
has  endeavoured  to  prove  this,  by  declaring  that  man,  in  a  state 
of  society,  feeds  more  than  is  absolutely  necessary  for  his  exigen- 
cies ;  and  that  he  becomes  plethoric  in  consequence ;  and  that  this 
condition  must  be  relieved  by  some  artificial  drain  in  the  male,  by 
hemorrhage  from  some  part  or  other  of  the  body ;  and,  in  the 
female,  by  the  menstrual  discharge. 

He  declares,  "  Que  le  flux  menstruel,  bien  loin  d'etre  une  in- 
stitution naturelle,  est  au  contraire  un  besoin  factice  contracte 
dans  I'etat  social."1  But  it  may  be  asked,  what  is  to  be  under- 
stood by  "I'etat  social?"  If  it  be  declared,  it  does  not  express 
the  condition  of  man  in  a  state  of  refinement,  it  must  be  admitted 
to  mean,  man  united  by  some  social  compact:  yet,  so  far,  wherever 
he  has  been  found,  we  have  unquestionable  proof  that  women 
menstruate;  notwithstanding  Roussel  declareSj  that  the  uterus  of 
.the  Brazilian  woman  does  not  perform  this  function. 

But,  were  this  true  with  these  particular  women,  (a  circum- 
stance much  to  be  doubted,)  it  would  be  but  an  exception,  and 
should  not  be  taken,  or  rather  mistaken,  for  the  rule.  Among 
all  the  aboriginal  females  of  this  country  hitherto  examined,  no 
such  exception  prevails  :  yet,  were  this  a  design  of  nature,  it  might 
most  reasonably  be  looked  for  among  these  varied,  widely  spread, 
and  simple  people. 

Why  this  opinion  of  Roussel  should  have  found  abettors,  it  is 
difficult  to  say ;  since  it  has  neither  facts  nor  reasoning  to  sustain 
it.  The  hypothesis  is  founded  upon  circumstances  totally  inade- 
quate to  the  effect — namely,  "  Les  hommes  resembles  ont  toujours 
cherche  &  resserrer  les  liens  de  la  cordialit6  dans  les  festins.  La 
joie  est  plus  vive,  et  les  6panchmens  plus  tendres  dans  ces  momens 
oft  la  machine  se  remonte  par  une  nouvelle  nourriture :  on  est 
ajors  plus  content  des  autres,  parcequ'on  est  plus  content  de 
soi  meme ;  1'absence  de  soucis  laisse  alors  £  la  nasure  la  liberte 
de  jouir  de  tous  ses  droits,  et  meme  d'en  abuser;  car  il  arrive 
souvent  que,  ne  demelant  plus  la  sensation  des  mets  d'avec  1'im- 
pression  de  la-gaite,  elle  prend  le  change,  et  se  surcharge  d'alimens 
qu'elle  croit  encore  necessaries,  longtemps  apres  que  le  besoin  est 
satisfait."2 

The  consequence  of  these  indulgences  he    supposes  to  be  a 

1  Systeme  Physique  et  Morale  de  la  Femme,  p.  113.  *  Ibid.  p.  1 13. 


HI  STORY    OF    MENSTRUATION.  81 

plethora ;  and  this  plethora  finds  an  abatement  in  the  female  by 
the  menstrual  discharge:  and  in  the  male,  by  hemorrhages  from 
various  parts  of  the  body,  according  to  the  period  of  life;  or  if 
the  hemorrhages  do  not  take  place,  the  consequences  of  the  ex- 
cess of  blood  show  themselves  in  a  variety  of  other  forms;  as  af- 
fections of  the  chest,  rheumatism,  hypochondriasm,  stone,  gout, 
asthma,  &c.,  &c. 

It  will  be  perceived  that  this  doctrine  is  but  a  modification  of 
the  one  long  before  promulgated  by  Galen — the  only  difference 
is  that  Galen  thought  women  were  ever  subject  to  the  menstrual 
discharge;  and  that  a  plethoric  condition  of  the  system  was  es- 
sential to  its  production:  while  Roussel  supposes  this  plethora  to 
be  of  artificial  origin;  and  that  the  menstrual  discharge  is  the 
fortuitous  consequence,  and  intended  to  relieve  the  system  from 
danger. 

A  few  observations  will  be  sufficient  to  destroy  this  curious 
and  ill-established  speculation.  1st.  From  no  record  of  the  his- 
tory of  the  human  race  does  it  appear  other  than,  that  the  fe- 
male was  always  obnoxious  to  this  discharge — thus,  by  Moses,  it 
is  distinctly  stated  to  have  obtained  among  the  women  of  his 
time,  and  we  have  every  reason  to  believe,  as  an  arrangement  of 
nature ;  so  also  among  all  the  tribes  of  the  most  savage  people. 
In  this  country,  most  abundant  proof  is  given,  in  the  journeys  of 
Major  Long,  that  the  menstrual  evacuation  is  a  constant  attend- 
ant on  the  females,  and  where  they  existed  in  the  greatest  pos- 
sible simplicity.  2d.  The  cause  assigned  by  Roussel,  namely 
"plethora,"  exists  where  this  discharge  has  been  interrupted;  and 
to  recall  the  menses  often  requires  the  abstraction  of  blood  and 
other  debilitating  remedies.  3d.  This  function  is  oftentimes  per- 
formed with  the  utmost  regularity,  and  in  the  accustomed  quan- 
tity, where  the  most  decided  debility  prevails.  4th.  That  this 
discharge  is  certainly  prevented,  however  long  and  regularly  it 
may  have  been  established,  by  the  removal  of,  or  from  the  dis- 
eased condition  of  the  ovaries.  5th.  That  an  abstraction  of 
blood  just  before  the  period,  or  at  any  other  time,  does  not  pre- 
vent it. 

Besides,  very  many,  indeed  all  the  mammiferous  animals, 
have  at  certain  periods  a  discharge  from  the  vagina,  which  is 
either  essential  to  fecundation,  or  gives  evidence  of  the  capacity 
for,  or  of  the  desire  of,  the  animal  at  that  moment  to  be  impreg- 
nated; and  this  discharge  is  sometimes  coloured,  accidentally, 
as  observed  above,  but  not  necessarily ;  and  that  this  evacua- 
tion is,  in  some  manner,  connected  with  impregnation,  is  evi- 
dent, since  it  never  appears,'' in  its  healthy  condition,  but  at  the 
periods  when  the  animal  is  capable  of  fecundation.1  It  is  equal- 

1  Frank  appears  to  be  of  a  different  opinion  upon  this  point ;  he  says  that  na- 

6 


82  HISTORY    OF    MENSTRUATION. 

ly  certain  that  the  human  female  is  also  capable  of  being  im- 
pregnated after  each  healthy  menstrual  period.  But  this  must 
be  taken  with  some  modification.  It  is  every  way  certain  there 
are  women  that  are  sterile  with  every  mark  of  complete  deve- 
lopment of  the  organs,  as  far  as  function  is  concerned,  and  as 
far  as  can  be  detected  by  the  eye  or  the  knife  of  the  anatomist. 
Yet  some  imperfections  must  exist,  for  fecundation  or  the  forma- 
tion of  healthy  ova  is  the  natural  arrangement;  but  the  product  of 
the  ovaria  is  not  always  in  a  condition  to  profit  by  the  application 
of  the  male  semen :  the  woman  remains  barren  for  life.  But  when 
these  failures  take  place,  can  we  be  certain  that  the  male  is  not 
in  fault  ?  We  know  this  to  be  so  in  some  instances.  We  have  more 
than  one  instance  where  the  woman  remained  barren  with  one 
husband,  to  become  a  widow,  and  prove  prolific  after  a  second  mar- 
riage. 

Nor  is  this  discharge  in  the  brute  a  mere  increase  of  quanti- 
ty of  the  ordinary  secretion  of  the  parts — it  differs  essentially 
from  it,  at  least  in  its  sensible  qualities ;  as  is  made  evident  to  the 
discriminating  olfactories  of  the  male.1  Thus  it  would  appear, 
that  nature  intended  some  end  should  be  answered  by  this  peculiar 
condition  of  even  the  brute  ;  is  it  not,  then,  equally  certain,  a  simi- 
lar end  is  answered,  in  the  human  female,  by  the  menstrual  evacua- 
tion ? 

Again,  this  discharge  commences  only  when  the  female  is  in  a 
condition  to  meet  and  overcome  the  ordinary  contingencies  of 
impregnation  and  delivery.2  Now,  were  this  merely  a  fortui- 
tous discharge,  why  should  it  occur  only  at  the  period  at  which 
the  female  can  propagate  her  species,  and  always  at  a  certain 
period  of  female  life  ?  For  I  must  protest  against  the  opinion 
of  Roussel  and  some  others,  who  suppose  impregnation  may  take 

ture  has  subjected  the  females  of  all  well-organized  animals  to  this  menstrual 
tribute,  but  that  she  does  not  always  Require  it  with  the  same  rigour;  that  is,  un- 
der the  penalty  of  sterility."  Now  we  think  Dr.  F.  has  assumed  rather  too  much 
in  his  hypothesis;  first,  because  there  are  sterile  animals,  and  we  believe  they  are 
only  so  in  the  absence  of  this  sign  of  coalescence;  for  it  is  constantly  the  practice 
of  breeders  of  animals,  to  wait  for  all  evidence  of  hpat  before  they  are  subjected 
to  the  male ;  secondly,  because  it  is  notorious  that  animals  do  not  conceive  if  put 
to  the  male  or  entirely  refuse  him,  if  this  modification  of  the  menses  be  not  pre- 
sent ;  thirdly,  he  is  certainly  of  opinion,  from  his  own  words,  that  it  is,  for  the 
most  part,  an  essential  to  generation;  and,  therefore,  must,  as  a  general  rule,  have 
been  intended  for  this  purpose ;  and  consequently,  if  impregnation  do  take  place, 
and  this  discharge  be  absent,  it  is  only  an  exception  to  the  rule  with  such  ani- 
mal, and,  in  this  respect,  is  like  the  human  female;  for  he  declares  that  this  has 
taken  place  in  females  so  circumstanced,  and,  therefore,  is  as  much  a  law  with  the 
one  as  with  the  other. 

1  "  In  some  animals,  the  reproductive  liquid  communicates  to  all  the  other  liquids 
a  strong  odour,  which  causes  both  this  species  and  the  sex  to  be  easily  distinguished." 
Walker  on  Intermarriages,  p.  40. 

4  Mr.  Bourne,  a  respectable  and  intelligent  South  Sea  missionary,  when  asked 
by  Mr.  Roberton,  "  Have  you  observed  that  early  marriages  (giving  the  ages  at 

"*/  .'&.' 

4 


HISTORY    OF    MENSTRUATION.  83 

/ 

place  before  the  menstrual  action  has  been  awakened,  or  after  it 
has  become  dormant.1 

That  impregnation  has  taken  place  before  there  was  a  coloured 
discharge  from  the  vagina,  and  even  after  it  has  ceased,  I  am  every- 
way willing  to  admit;  but  neither  of  these  circumstances  proves  the 
absence  of  the  menstrual  action,  or  that  action  which  only  exists 
during  the  integrity  of  the  ovaria,  but  which  ceases,  or  never  takes 
place,  when  these  bodies  are  imperfect ;  and  wliich  action  is  essen- 
tial, either  directly,  or  indirectly,  to  impregnation. 

Roussel*  declares  menstruation  to  be  "  less  a  cause  than  a  sign 
of  fecundity."  In  this  I  agree  :  for  the  menstrual  action  cannot 
be  a  cause  of  fecundity,  since  this  capacity  is  known  to  depend 
upon  the  ovaria.  Yet  it  is  every  way  essential  to  propagation,  that 
the  internal  secreting  surface  of  the  uterus  be  in  a  healthy  condi- 
tion, .and  this  manifested  by  a  healthful  catamenial  discharge ;  or, 
in  other  words,  only  when  the  quantity  and  quality  of  the  menses 
are  free  from  objection,  and  the  ovaries,  at  the  same  time,  in  per- 
fect health. 

SECT.  II. — Causes  which  may  diminish  capacity,  <frc. 

It  may,  therefore,  be  considered  as  highly  probable,  that  the  ab- 
sence of  the  capacity  to  be  impregnated,  will  sometimes  depend 
upon  the  imperfect  condition  of  either  the  uterus  itself,  or  of  the 
ovaries.  If  the  former,  it  may  consist  in  some  derangement  of  the 
secreting  surface  of  this  organ  ;  for  though  there  may  be  a  regular 
discharge  of  a  coloured  fluid,  and  this  so  nearly  resembling  the 
perfect  secretion  as  to  deceive  the  senses,  it  may  yet  want  an  es- 
sential condition  or  quality,  and  thus  entail  barrenness — hence,  ail 
women  are  not  fruitful  who  may  have  a  regular  catamenial  dis- 
charge ;  though,  as  far  as  can  be  determined  by  appearances,  this 
discharge  is  every  way  healthy,  and,  at  the  same  time,  the  ovaries 
free  from  fault. 

Nor  is  it,  perhaps,  difficult  to  explain,  or  rather  to  imagine, 
how  this  may  happen.  I  adopt  the  opinion  that  .the  menstrual 

• 

which  they  occur)  are  generally  soon  productive?"  answered,  that  in  very  early 
marriages  several  years  elapsed.  In  this  Mr.  Ellis,  the  celebrated  missionary,  con- 
curred.—  Mr.  Robertonon  Menstruation,  Edinburgh  Medical  and  Chirurgical  Jour- 
nal for  October,  1832. 

This  would  seem  to  prove  the  position  laid  down  in  the  text.  For  it  was  Ion* 
since  observed  by  Mr.  John  Hunter,  that  when  a  woman  begins  to  breed  at  an 
early  period,  as  at  fifteen,  and  has  her  children  fast,  she  seldom  breeds  longer 
than  thirty  or  thirty-five;  -hence  we  may  suppose  either  that  the  parts  are  then 
worn  out,  or  that  the  breeding  constitution  is  over.  If  a  woman  begins  older,  a> 
at  twenty  or  twenty-five,  she  may  continue  to  breed  to  the  age  of  forty  or  more.  ' 
— Phil.  Trans,  vol.  Ixxvii.  p.  233. 

1  Does  it  not  seem  extraordinary  that  the  plethora  of  Roussel  should  not  exist 
until  a  certain  period  of  life,  (puberty;)  and  this  period  uniformly  modified  by 
climate,  &c.,  or  that  it  should  not  take  place  after  another  certain  period  of  life, 
(after  the  cessation  of  the  menses,)  to  maintain  this  discharge?  '  Page  117. 


84  HISTORY    OF    MENSTRUATION. 

discharge  is  a  genuine  secretion,  and  that  the  internal  face  or 
lining  of  this  organ  is  the  portion  which  furnishes  it ;  now,  it  will 
be  evident,  that  whenever  this  part  is  in  any  way  deranged,  the 
quality  of  its  product  must  also  be  impaired;  but  the  injury  does 
not  consist  so  much  in  the  imperfect  elaboration  of  the  menstrual 
fluid,  as  in  the  inability  of  this  surface  to  furnish  a  healthy  deci- 
dua  after  impregnation  has  taken  place ;  for  there  can  be  little 
doubt  but  that  the  same  apparatus  furnishes  both  one  and  the  other. 
This  condition  of  the  uterus,  I  have  reason  to  think,  is  not  of  un- 
frequent  occurrence:  an  ovum  may  be  fecundated,  and  duly  con- 
veyed to  the. cavity  of  the  uterus  ;  but  it  perishes  there,  from  the 
want  of  a  healthy  decidua:  it  is,  therefore,  cast  off  unperceived 
at  the  next  menstrual  purgation ;  and  thus  the  woman  is  relatively 
barren. 

What  strengthens  this  opinion  is,  that  this  lesion  of  the  uterus  is 
frequently  repaired,  by  either  proper  remedies,  or  by  the  powers 
of  the  system  alone ;  and  the  woman  afterwards  becomes  fruitful. 
I  am  fully  persuaded  I  have  witnessed  a  number  of  such  cases. 

If  it  depend  upon  an  imperfection  of  the  ovaria,  it  may  not, 
perhaps,  admit  of  relief.  The  diseases  of  the  ovaria  may  consist, 
1st,  in  their  imperfect  development;  2dly,  in  derangement  of 
structure ;  3dly,  in  a  want  of  healthy  organization  of  the  ova 
themselves.  Now,  either  of  these  conditions  of  the  ovaria  may  be 
so  complete  as  to  altogether  destroy  their  influence  upon  the  secre- 
ting surface  of  the  uterus ;  the  catamenial  discharge  may,  there- 
fore, continue,  with  all  due  regularity,  and  yet  the  woman  may  be 
barren ;  and,  hence,  this  discharge  cannot  be  considered,  rigidly, 
as  a  constant  sign  of  fertility. 

Yet  it  may  be  safely  admitted,  as  a  general  rule,  that  women 
who  menstruate  regularly  and  without  pain,  or  the  expulsion  of 
coagula,  or  false  membrane,  are  fecund;  and  that  the  reverse  of 
these  conditions  is  almost  sure  to  be  attended  with  sterility.  It 
may  also  be  observed,  that  we  cannot  attach  much  consequence 
to  the  quantity  evacuated;  for  the  woman  who  may  evacuate 
double  the  quantity  of  another  is  not  for  this  reason  more  cer- 
tainly prolific.  I  have  known  a  number  of  instances  of  repeated 
impregnations,  where,  as  far  as  could  be  ascertained,  not  more 
than  two  ounces  were  habitually  evacuated ;  and  this  not  occupy- 
iag  more  than  a  day  and  a  half,  or  two  days,  for  its  elimination ; 
while,  on  the  contrary,  I  have  known  women  who  were  barren, 
discharge  three  or  four  times  this  quantity ;  and  the  fluid  bear  all 
the  sensible  marks  of  a  healthy  secretion.  From  this  it  would 
appear,  that  mere  regularity  in  returns ;  the  elimination  of  a  pro- 
per quantity  of  fluid,  and  this  fluid  apparently  of  a  healthy  cha- 
racter, do  not  always  declare  the  woman  to  be  fecund.  Yet, 
when  the  woman  has  never  menstruated,  or  when  this  discharge 
has  altogether  ceased,  agreeably  to  the  ordinary  arrangement  of 


HISTORY    OP    MENSTRUATION.  85 

nature  or  from  disease,  she  either  never  becomes  impregnated,  or 
ceases  to  become  so,  if  she  ever  has  been. 

It  is  true  we  are  told,  as  observed  before,  by  highly  respecta- 
ble authority,  that  impregnation  has  taken  place  before  the  erup- 
tion of  the  menses,1  as  well  as  after  their  final  cessation.  The 
explanation  of  this  seeming  exception  is  not  difficult,  for  the  rea- 
son already  assigned ;  namely,  that  because  a  coloured  fluid  was 
not  observed,  it  was  taken  for  granted  that  the  uterus  had  never 
assumed  the  menstrual  action,  or  had  not  resumed  it  after  it  had 
ceased  as  a  law  of  the  system. 


SECT.  III. — Early  Appearance  of  the  Menses. 

Now,  it  is  admitted  by  practical  writers,2  as  a  fact  of  no  very 
rare  occurrence,  that  the  menstruous  evacuation  is  sometimes 
serous,  and  this  for  several  periods  before  the  menstrual  blood, 
properly  so  called,  shows  itself,  to  more  decidedly  mark  the  esta- 
blishment of  the  process.  This  is  especially  the  case  with  those 
who  have  this  discharge  to  commence  early. 

And  it  may  be  well  to  caution  the  young  practitioner  against 
a  common  and  natural  error, — when  this  anticipating  discharge 
takes  place,  not  to  mistake  it  for  leucorrhcea,  and  attempt  its  sup- 
pression. We  shall  have  occasion,  in  another  place,  to  point  out 
the  influence  of  leucorrhcea  upon  the  menstruous  discharge.  See 
Sec.  on  the  Tardy  Appearance  of  the  Menses. 

I  was  consulted,  some  months  since,  in  the  case  of  a  young 
lady  between  twelve  and  thirteen  years  of  age,  who  was  labour- 
ing under  a  diseased  spine,  but  who  was  also  afflicted  with  head- 
ach,  palpitations  of  the  heart,  and  great  sickness  of  stomach. 
She  had  also  at  somewhat  regular  periods  a  pain  in  the  small  of 
the  back,  with  a  bearing  down  sensation,  a  desire  to  pass  water, 
an  inclination  to  go  to  stool,  &c.  From  these  circumstances  her 
mother  concluded,  and  in  this  I  concurred,  that  an  effort  was 
making  for  the  production  of  the  menses,  though  the  common 
external  signs  of  puberty  were  almost  entirely  wanting.  I,  how- 
ever, requested  the  mother  to  be  careful  in  examining  the  linen 
worn  by  her  daughter  at  these  periods,  and  ascertain  whether 
there  was  not  a  discharge  from  the  vagina  resembling  leucor- 
rhosa.  This  was  done:  she  reported  there  were  considerable 
marks  upon  her  linen ;  and  this  was  observed  for  at  least  four 

1  Rondelet  mentions  a  woman  who  wa3  delivered  twelve  times ;  and  Joubert 
another,  who  bore  eighteen  children,  neither  of  whom  had  ever  menstruated — 
Gardien  Traite  <T Accouchement ,  Vol.  I.  p.  220. 

*  Gardien  says,  "  Si  quelqnefois  le  sang  sort  brusquement  sous  couleur  rouge, 
le  plus  constammant  les  regies  commencement  par  un  flux  asreux  et  h'nissent  de 
meme."— Traite  Complet.  d'Accouchemens,  Vol.  I.  p.  238. 


86  HISTORY  OF   MENSTRUATION. 

periods :  after  this  the  menses,  with  their  usual  appearances,  were 
established,  and  continued  with  tolerable  regularity  up  to  the 
present  time.  This  is  the  third  instance  I  have  witnessed  of 
rather  precocious  menstruation  in  girls  with  diseased  spines ; 
whether  there  be  a  connexion  between  this  affection,  and  the 
functions  of  the  uterus,  must  be  left  to  future  observations  to  de- 
termine. 

Thus,  we  see  it  is  easy  to  err  on  this  point  with  young  girls, 
and  to  suppose  they  may  have  conceived  before  the  catamenial 
period  had  commenced;  nor  is  the  error  less  liable  to  be  made 
in  those  rare  instances  of  impregnation,  after  the  final  cessation 
is  supposed  to  have  taken  place ;  for  in  several  well-attested  in- 
stances of  pregnancy  at  advanced  periods  of  life,  it  was  found, 
upon  close  examination,  an  effort  had  been  made  by  the  system  to 
restore  the  catamenial  flux  by  a  periodical  serous  discharge. 

In  one  case,  which  fell  in  part  under  my  own  notice,  this  effort 
was  certainly  made ;  but  perhaps  without  the  knowledge  of  the 
person  concerned ;  yet  it  was  sufficiently  evident  to  the  indivi- 
dual who  washed  her  clothes,  and  who  furnished  me  with  the 
account;  for  it  is  presumable,  with  such  evidence  of  returning 
youthfulness,  she  would  scarcely  have  risked  the  consequences 
which  followed  her  amour. 

I  was  requested,  in  the  month  of  March,  1795,  to  visit  a  young 
child,  ill  with  the  natural  small-pox.  At  almost  every  visit  I  paid 
the  child,  I  observed  an  aged  woman  much  afflicted  at  its  danger- 
ous condition.  Having  an  opportunity  during  the  absence  of 
this  person  to  inquire  who  she  was,  I  was  informed,  to  my  great 
surprise,  that  she  was  the  mother  of  the  child.  I  thought  my 
informant  was  attempting  to  impose  upon  me,  and  told  her  so; 
but  she  seriously  declared  I  might  rely  upon  the  fact.  I  was  now 
informed  that  the  mother  of  the  child  had  never  been  married, 
and  that  she  was  in  her  sixty-first  year  when  the  child  was 
born. 

The  case  interested  me  much,  and  my  inquiries  became  more 
particular ;  and  from  much  conversation  I  learnt,  that  the  old 
woman  had  ceased  to  menstruate  at  forty-five,  but  that,  about 
two  years  before  the  period  of  my  attendance  on  the  child,  she 
(the  nurse  of  the  child,  and  the  washerwoman  of  the  mother,) 
had  observed  monthly  evidence  of  a  return  of  the  catamenia;  it 
was  not  much  coloured,  yet  sufficiently  so  to  excite  attention. 
Now,  this  case  would  certainly  pass  for  an  instance  of  impregna- 
tion after  the  menses  had  ceased;  and  it  must  be  admitted  to  be 
one  every  way  calculated  to  mislead.  I  have  therefore  concluded, 
fhat  the  cases  upon  record,  purporting  to  be  of  this  kind,  may  have 
been  similar  to  the  one  now  related.1 

1  A  case  is  related  in  the  Edinb.  Ann.  Register,  Vol.  IX.  p.  608,  of  a  Mrs. 
Ashby,  of  Firnby,  near  Spilsby,  who  was  delivered  of  twins  in  her  fifty-fourth 


HISTORY  OF   MENSTRUATION.  87 

So  far,  facts  seem  to  oppose  the  idea,  that  impregnation  can 
take  place  before  the  menstrual  action  has  been  established,  and 
after  it  has  finally  ceased :  let  us  now  see  if  reasoning  will  not 
corroborate  them. 

It  will  not  be  disputed,  that  a  part  cannot  perform  its  peculiar 
or  appropriate  action,  until  such  part  is  completely  developed,  or 
its  organization  perfected ;  consequently  the  uterus  will  not  be 
subject  to  the  menstrual  action,  until  the  surface  which  furnishes 
this  fluid  is  perfect  in  its  arrangement ;  and  not  then,  unless  it 
receive  the  peculiar  stimulus  given  by,  or  it  sympathize  with,  the 
perfect  ovarium,  or  ovaria.  Now,  by  all  we  learn  from  either 
experiment  or  accident,  it  is  certain,  that  the  menstrual  action  is 
for  ever  prevented  by  the  extirpation  or  destruction  of  the  ovaria  ; 
consequently,  this  action  is  dependent  for  its  existence  upon  a 
state  of  perfectness  of  one  or  both  of  these  bodies. 

It  is  equally  certain,  that  if  the  ovaria  be  incomplete,  they  can- 
not furnish  perfect  ova,  or  ova  capable  of  fecundation :  nor  can 
they  give  or  excite  that  action  which  furnishes  the  nienstruous 
fluid.  If,  on  the  other  hand,  the  ovaria  be  properly  developed, 
and  the  menstrual  action  does  not  take  place,  it  is  but  reasonable 
to  suppose,  that  some  imperfection  must  exist  in  the  uterus  itself; 
and  if  this  be  admitted,  it  would  seem  to  follow,  that  a  perfect 
action  cannot  be"  expected  from  an  imperfect  organ ;  and  it  will 
be  farther  granted,  that  no  process  in  the  human  system  requires 
greater  perfection  of  organs,  than  those  subservient  to  genera- 
tion. 

Therefore,  as  regards  the  main  point,  it  is  unimportant  whe- 
ther the  imperfection  be  seated  in  the  ovaria,  or  in  the  secreting 
surface  of  the  uterus ;  for,  if  it  exist  in  either,  coition  cannot  be 
entirely  successful.  If  an  ovarium  furnish  a  perfect  ovum,  it 
may  be  fecundated,  though  the  menstrual  action  had  never  taken 
place ;  but  this  is  but  one  step  in  the  march  of  generation ;  for  if 
the  ovum  be  not  properly  cherished  after  it  shall  have  been  de- 
posited in  the  uterus,  it  will  soon  perish  and  be  cast  off.  For, 
that  it  may  be  sustained  and  properly  developed,  it  is  essential, 
that  the  uterus  produce  the  decidua ;  and  that  it  cannot  furnish 
this  sine  qua  non.  is  highly  probable,  as  the  organization  which 
is  to  yield  it  is  the  same  as  that  which  performs  the  menstrual 
secretion ;  and  that  this  part  is  imperfect  is  put  beyond  doubt, 
since  it  has  formed  this  fluid. 

That  impregnation  may  be  successful,  a  healthy  condition  of 
the  internal  surface  of  the  uterus  is  required,  and  a  sound  condi- 
tion of  at  least  one  of  the  ovaria.  For  if  these  organs  be  imper- 
fect, either  fecundation  cannot  result,  or  it  will  take  place  una- 

year;  and  Haller  gives  instances  still  more  extraordinary — viz.  one  at  fifty-eight, 
one  at  sixty-three,  and  another  at  seventy. 


88  HISTORY    OF    MENSTRUATION. 

vailingly.  Thus,  if  the  ovaria,  from  disease  or  imperfection, 
cannot  furnish  an  ovum  that  can  profit  by  the  application  of  the 
male  semen,  fecundation  will  not  issue :  if,  on  the  other  hand,  the 
internal  face  of  the  uterus  be  diseased,  and  incapable  of  furnish- 
ing the  decidua,  the  ovum  must  perish,  though  fecundated.  It 
is,  therefore,  but  reasonable  to  conclude,  that  if  the  uterus  be 
not  sufficiently  developed  to  secrete  the  menstruous  fluid,  it  must 
be  imperfect ;  and  if  imperfect,  it  cannot  perform  what  is  essential 
for  the  preservation  of  the  ovum  after  it  has  been  placed  in  its 
cavity. 

Fecundation,  after  the  cessation  of  the  menses,  must  be  equally 
doubtful ;  since  it  is  probable  it  would  require  a  renewal  of  the 
raenstruous  action,  that  fecundation  should  be  successful.  At 
present  we  are  not  sufficiently  acquainted  with  the  conditions  es- 
sential to  this  cessation ;  or,  in  other  words,  what  changes  take 
place  in  either  the  ovaria,  or  in  the  secreting  surface  of  the  uterus 
itself,  when  this  period  arrives.  We  only  know  it  does  take  place ; 
but  how,  we  are  altogether  ignorant.  The  moral  cause  of  the 
cessation  is  better  comprehended  than  the  physical. 

It  would  seem  but  fair  to  conclude,  that  if  the  early  part  of 
female  life  requires  a  certain  condition  of  the  uterus  and  ovaria, 
to  render  coition  successful,  it  would  be  no  less  necessary  at  the 
more  advanced  stage :  I  have  attempted  to  prove  this  necessity  ; 
and  the  same  arguments  will  also  serve  for  the  latter  period.  For, 
it  is  evident,  that  the  ovaria  and  uterus  must  have  suffered  a 
change,  or  the  woman  would  have  continued  to  menstruate :  now, 
it  is  of  little  moment  whether  the  change  occur  in  the  uterus  or  in 
the  ovaria ;  since  a  certain  alteration  in  either  will  incapacitate 
the  woman  both  for  menstruation  and  conception. 

It  is,  however,  probable,  that  the  ovaria  suffer  deterioration 
earlier  than  the  uterus ;  as  many  women  continue  to  menstruate 
regularly  for  a  considerable  time,  before  the  final  cessation,  with- 
out conceiving.  The  ovaria  may  cease  to  produce  ova  to  be 
fecundated  j  and  the  absence  of  this  power  may  eventually  cause 
the  final  departure  of  the  menses ;  since  they  would  be  no  longer 
necessary,  or  useful. 

It  is,  also,  probable,  from  impregnation  now  and  then  taking 
place  long  after  the  disappearance  of  the  menses,  that  an  ova- 
rium  may  regain  its  productive  powers,  and  furnish  a  new  and 
healthy  ovum;  and  when  it  does  regain  this  capacity,  the  in- 
ternal face  of  the  uterus  may  reassume  its  menstrual  action,  and 
impregnation  may,  under  such  circumstances,  be  the  consequence. 
But  that  it  may  be  eventually  successful,  precisely  the  same  con- 
dition of  the  uterus  must  exist,  namely,  the  formation  of  the 
decidua;  as  when  this  process  was  successful  in  the  earlier  periods 
of  life ;  for  if  this  be  wanting,  the  same  consequences  must  ne- 
cessarily follow  as  would  then  result. 


HISTORY    OF    MENSTRUATION.  89 

It  seems  that  the  production  of  efficient  ova  is  governed  by 
some  general  law  in  each  individual  female;  in  the  brute  it  is 
regulated  with  great  exactness,  as  they  have  regular  periods  of 
salacity;  and  this  salacity  may  depend  upon  the  presence  of  a 
perfected  ovum  or  ova.  In  the  human  female  these  periods  are 
not  so  exactly  limited,  as  individuals  differ  very  much  in  their 
capacity  to  be  impregnated;  and  each  has  a  marked  period, 
caeteris  paribus.  Thus,  some  women  are  impregnated  every 
twelve  or  thirteen  months;  others  are  eighteen  months  or  two 
years;  while  others  enjoy  much  longer  intervals. 

I  know  a  lady  who  conceived  but  once  every  seven  years,  and 
she  bore  four  children  at  these  intervals.  I  have  known  seve- 
ral to  have  a  lapse  of  three  years  between  each  pregnancy,  &c. 
It  would  seem,  from  these  facts,  that  it  requires  a  lapse  of  a  cer- 
tain period  to  perfect  an  ovum;  and  that  this  process  is  much 
more  rapid  in  some  instances  than  in  others.  But  when  the 
ovaria  lose  the  power  of  furnishing  ova,  as  at  the  cessation  of 
the  menses,  impregnation  ceases  of  course.  The  ovaria  some- 
times, however,  regain  the  power,  after  it  has  been  long  lost,  of 
furnishing  healthy  ova,  or  they  become  much  more  tardy  in  pro- 
ducing them,  as  a  woman  will  have  much  longer  intervals ;  or 
this  may  be  accelerated,  if  she  have  been  tardy;  therefore, 
some  women  have  their  children  at  uncertain  intervals  ;  one 
lady  with  whom  I  was  acquainted,  had  not  a  child  until  she  had 
been  married  19  years;  her  husband  was  a  hale,  hearty-looking 
man  as  one  in  a  thousand.  She  never  became  impregnated 
again.  And  I  have  known  more  than  one  instance,  where  the 
lady  had  seven  children  in  six  years,  &c. 

Impregnation  after  the  final  cessation  of  the  menses  is  of  ex- 
tremely rare  occurrence,  and  should  be  ranked  among  those  ex- 
traordinary instances,  in  which  the  system  makes  an  attempt  to 
renew  certain  lost  functions,  or  to  repair  lost  parts.  Thus,  the 
eye-sight  has  been  restored,  after  having  remained  imperfect 
many  years;  the  hearing,  in  like  manner,  has  returned  after  long 
deafness ;  the  teeth  have  been  renewed  after  they  have  been 
many  years  lost,  &c.  Is  it  not  then  more  than  probable,  that 
when  such  cases  occur,  all  the  functions  ordinarily  esteemed  es- 
sential to  this  process  in  the  early  part  of  life,  should  obtain 
when  it  takes  place  after  the  menses  have  ceased?  Now  a 
healthy  menstrual  action  is  a  sine  qua  non  to  impregnation,  in 
the  earlier  parts  of  life ;  it  would  seem,  therefore,  to  be  indis- 
pensable to  this  end,  at  the  latter  period:  and  where  impregna- 
tion has  obtained,  we  cannot  well  question,  but  it  has  been  pre- 
ceded by  this  action. 


90  HISTORY    OF    MENSTRUATION. 


SECT.  IV. — The  time  at  which  they  appear. 

The  period  at  which  the  menses  make  their  appearance  is  va- 
riable; it  is  much  influenced  by  constitution,  climate,  and  mode 
of  life.  As  a  general  rule,  it  takes  place  at  puberty,  or  at  that 
period  at  which  the  female  is  capable  of  propagating  her  species; 
and  this  period  varies,  as  climate  may  differ.1  They  constantly, 
however,  keep  pace  with  the  development  of  the  body;  where 
this  is  rapid,  they  will  appear  proportionably  earlier;  where  this 
process  is  slower,  they  will  appear  later:  but  whenever  the 
menses  appear  as  regular  evacuations,  they  mark  the  period  of 
puberty;  thus,  in  hot  countries,  women  commence  to  menstruate 
at  eight  or  nine  years  of  age,  and  are  not  unfrequently  mothers 
at  ten. 

In  the  more  northern  regions,  as  in  Lapland,  &c.,  this  evacua- 
tion is  generally  delayed  until  the  female  has  attained  her  eigh- 
teenth or  nineteenth  year ;  in  the  temperate  latitudes,  the  average 
period  will  be  found  from  the  fourteenth  to  the  sixteenth  year. 
A  difference  will,  nevertheless,  be  found  in  the  women  who  may 
reside  in  cities,  and  in  those  who  dwell  in  the  country  of  each 
respective  portion  of  the  globe.  It  may  also  be  observed,  that 
in  cold  countries,  women  continue  to  menstruate  for  a  longer 
period  than  in  warm:  for  as  a  general  rule,  it  will  be  found,  they 
are  obnoxious  to  this  discharge,  double  the  period  that  elapses 
before  it  commences.  Thus,  women  who  have  not  this  discharge 
until  eighteen,  will  be  found  to  have  it  until  beyond  fifty ;  those 
who  commence  at  fourteen  or  fifteen,  will  leave  off  at  about 
forty-five;  those  who  begin  so  early  as  eight  or  nine,  will  have 
it  cease  at  twenty-five  or  six :  "  citius  pubescunt,  citius  senes- 
cunt." 

This  fact  appears  to  be  disputed  by  Frank  :a  he  "  says  that  the 
early  appearance  of  the  menses  does  not  hasten  the  period  of 
cessation ;  for  in  the  Milanese,  where  he  practised  ten  years,  this 
discharge  takes  place  one  or  two  years  earlier  than  in  Germany; 
yet  it  is  no  uncommon  thing  to  see  women  perfectly  regular  at 
the  forty-eighth  or  fiftieth  year."  This  may  be,  and  most  pro- 
bably is  the  case — but  this  account  tells  but  the  half  that  is  ne- 
cessary to  the  establishment  of  the  law  he  lays  down ;  for  he  has 
not  declared  that  the  females  he  found  regular  at  forty-eight  or 
fifty,  had  in  every  instance  begun  a  year  or  two  sooner  than  the 

1  We  have  heard  of  a  lady,  within  a  few  days,  who  is  now  fifty  years  of  age, 
who  did  not  commence  to  menstruate  until  she  was  forty-five;  then  she  menstru- 
ated regularly  until  the  present  time  (Dec.  1MO.)  We  know  well  a  lady,  aged 
twenty-three  years,  who  menstruates  but  once  in  a  year. 

1  Traite  de  Mcdecine  Pratique,  torn.  3,  p.  397. 


HISTORY    OF    MENSTRUATION.  91 

women  of  Germany,  and  which  would  be  essential  to  the  fact  he 
thus  attempts  to  prove.1 

There  are,  however,  a  number  of  curious  objections  to  the 
general  rules  we  have  attempted  to  lay  down :  these  consist  in 
the  precocious  appearance2  and  unusual  protraction  of  the  menses. 
Haller,  Van  Sweiten,  &c.,  give  instances  of  each  kind.  I  have 
seen  several  cases  where  this  discharge  was  regularly  continued 
until  the  fifty-fourth  or  fifty-fifth  year.3 


SECT.  V. — Symptoms  which  announce  their  approach. 

This  evacuation  rarely  fails  to  be  announced  by  a  variety  of 
symptoms,  of  greater  or  less  severity,  or  danger ;  among  girls 
who  have  been  delicately  and  luxuriously  brought  up,  and  who 
have  their  nervous  system  rendered  morbidly  sensible  or  vibra- 
tile,  a  great  variety  of  nervous  symptoms,  as  they  are  called, 
precede  the  eruption  of  the  menses;  such  as  ringing  in  the  ears  ; 
a  sense  of  suffocation;  palpitation  of  the  heart;  starting  from 
slight  and  sudden  noises;  precarious  and  whimsical  appetite; 
loathings  and  cravings;  convulsive  twitchings;  convulsions;  cho- 
rea sancti  viti,  &c.,  all  of  which  are  sometimes  instantly  relieved 
by  a  trifling  discharge  from  the  vagina,  and  this  not  necessarily 
coloured. 

.    The  last  mentioned  circumstance  must  have  been  observed 
by  every  attentive  practitioner,  who  may  have  had  charge  of 

*  We  could  record  a  number  of  instances  where  the  menses  were  continued 
much  beyond  their  ordinary  period,  and  where,  after  ceasing  some  time,  were 
resumed  with  their  accustomed  regularity;  but  we  shall  limit  our  observations 
to  one  case,  and  that  because  it  is  recent  and  well  authenticated.     This  case  is 
recorded  in  the  Ann.  Univ.  de  Med.     A  female  aged  ninety-four  continued  to 
menstruate  from  the  fifty-third  to  the  ninety-fourth  year.     Her  relatives  were  re- 
markable for  their  longevity;  she  is  at  present  in  perfect  health. — American  Journ. 
of  the  Medical  Sciences  for  Feb.  1831. 

1  There  have  been  instances  of  the  catamenia  commencing  soon  after  birth. 
An  instance  of  this  kind  is  given  by  Mr.  Whitmore,  in  Med.  Chirur.  Trans.  Lon- 
don, vol.  4th.  This  patient  had  the  evacuation  regularly  from  birth,  at  stated 
intervals  of  three  weeks.  In  her  fourth  year  she  died  after  a  very  short  illness. 
On  dissection,  an  unusual  development  of  the  uterus,  &c.,  was  discovered.  The 
other  daughters  of  this  family  had  nothing  peculiar. 

*  The  following  table  exhibits  the  ages  of  three  hundred  and  twenty-six  fe- 
males, at  which  they  began  to  menstruate.     It  is  furnished  by  Mr.  Roberton,  in 
the  North  of  England  Medical  and  Surgical  Journal. 

In  their  llth  year,  6.  In  their  Kith  year,  54. 

12th     «     12.                                                       17th     "  50. 

13th    «     31.                                                       Hth     "  Ifl. 

14th     «     60.                                                       J9th     "  18. 

15th    «    72.                                                    20th    "  4. 

To  this  list  may  be  added  the  case  related  by  Madame  Boivin,  in  her  account 
of  a  new  cause  of  abortion.  The  subject  of  this  case  commenced  to  menstruate 
at  seven  years  of  age,  and  did  so  regularly  after  her  tenth  year. 


92  HISTORY    OF    MENSTRUATION. 

females ;  and  it  is  one  worthy  of  note,  as  it  goes  to  confirm  what 
has  been  advanced  above  of  the  identity  of  the  action  which  pro- 
duces these  fluids,  though  so  different  in  their  appearance. 

The  vascular  system  is  sometimes  also  much  disturbed:  we 
often  witness  determinations  of  blood  to  various  parts  of  the 
body ;  as  to  the  head ;  the  lungs ;  the  mammse ;  the  stomach  and 
bowels,  &c.;  for  the  relief  of  which,  we  are  obliged  to  abstract 
blood,  or  employ  other  remedies,  if  a  kindly  discharge  from  the 
uterus  do  not  quickly  tranquillize  the  disturbed  and  embarrassed 
circulation. 

Sometimes  the  inconveniences  are  confined  to  the  genital  sys- 
tem— in  such  cases,  a  sense  of  weight;  bearing  down:  ardor 
urinae;  pain  in  the  region  of  the  uterus,  &c.,  are  experienced;  all 
of  which,  for  the  most  part,  announce  the  approaching  dis- 
charge. 

It  is  at  this  period,  also,  that  nature  perfects  her  work,  both  as 
regards  development  and  proportion ;  it  is  the  period  of  the  most 
perfect  beauty  of  which  the  female  is  susceptible ;  it  is  the  one 
at  which  the  moral  changes  are  not  less  remarkable  than  the 
physical;  it  is  a  moment,  of  all  others,  the  most  replete  with 
consequences  to  the  inexperienced  and  confiding  female. 

At  this  period  a  great  variety  of  interesting  and  curious  phe- 
nomena present  themselves:  the  voice  is  found  to  change  ;  the 
neck  and  throat  to  increase  in  size,  and  to  become  more  symme- 
trical ;  the  mammae  to  swell ;  the  nipple  to  protrude ;  the  chest 
to  expand ;  the  eyes  to  acquire  intelligence,  and  an  increase  of 
brilliancy;  in  a  word,  a  new  being,  almost,  is  created. 

The  quantity  of  fluid  expended  at  a  menstruous  period  differs 
in  different  individuals ;  with  girls  who  precociously  menstruate, 
the  quantity  is  in  general  smaller,  and  the  returns  less  regular. 
Climate  exerts  an  influence  upon  the  quantity  discharged,  as  well 
as  upon  the  periods  at  which  this  evacuation  shall  commence. 
Thus,  in  the  equatorial  and  more  northern  regions,  it  is  less  than 
in  the  more  temperate  climates.1 


SECT.  VI. — Quantity  discharged. 

A  variety  of  causes,  independent  of  climate,2. are  said  to  have 
the  power  of  increasing  the  menstrual  discharge ;  as  all  circum- 

'  Gardien,  p.  227. 

"  Of  this  several  instances  have  occurred,  to  prove  that  uterine  development 
may  be  independent  of  the  general  influence  of  climate ;  for  a  case  is  mentioned, 
that  in  Kentucky  a  girl  of  eleven  was  safely  delivered  of  a  living  child ;  the  parent 
bore  all  the  usual  marks  of  complete  development.  And  another  instance  has  been 
communicated  to  me  by  Mr.  William  M.  Egbert,  in  which  a  girl  in  New  Jersey 
became  a  mother  at  twelve ;  and  is  now  the  mother  of  several  other  children. 


HISTORY   OF   MENSTRUATION.  93 

stances  suited  to  increase  the  activity  of  the  system  ;  and  thus 
tend  to  its  more  hasty  development.  Such  are  the  passions  of  the 
mind,  frequently  indulged  in,  as  anger  and  joy;  a  diet  rendered 
too  stimulating  by  either  spices  or  spirits  of  any  kind.  All  such 
as  would  have  a  tendency  to  produce  a  plethora  of  the  uterus, 
and  thus  increase  its  sensibility ;  as  the  frequent  use  of  foot- 
baths, foot-stoves,  &c.,  all  such  as  excite  a  pruriency  of  the  ima- 
gination ;  and  lastly  those  which  augment  the  quantity  of  blood, 
as  too  full  a  diet,  especially  chocolate  as  a  constant  article  of 
food  ;J  too  long  indulgence  in  feather  beds,  and  the  want  of 
sufficient  exercise. 

It  would  be  difficult  to  ascertain  the  exact  quantity  of  fluid 
evacuated  at  each  period,  as  it  cannot  be  well  subjected  to  mea- 
surement ;  hence  the  discrepancies  upon  this  subject.  Hippocra- 
tes set  it  down  at  twenty  ounces ;  there  can  be  no  doubt  but 
this  is  very  much  overrated ;  at  an  average,  from  four  to  six 
ounces  may  be  considered  as  the  proper  mean.  It  usually  em- 
ploys from  three  to  six  days  for  its  evacuation,  and  for  the  most 
part  is  extremely  regular  in  its  returns.  I  know  a  number  of 
females  who  can  tell  not  only  the  day  on  which  it  will  return, 
but  even  indicate  the  hour  at  which  it  will  show  itself.3  With 
other  females,  however,  it  is  less  regular:  but  it  rarely  exceeds 
the  twenty-eighth  day  with  such  as  are  in  good  health,  if  we  ex- 
cept when  it  approaches  the  period  for  its  final  cessation. 

When  the  time  approaches  at  which  this  evacuation  is  about  to 
•  cease,  agreeably  to  the  arrangement  of  nature,  this  flux  becomes 
more  desultory,  as  regards  the  periods  of  return,  and  the  quan- 
tity eliminated.  The  discharge  may  return  every  two  or  three 
weeks,  or  it  may  procrastinate  until  the  fifth  or  sixth  week,  or 
sometimes  even  longer;  and  instead  of  the  four  or  five  ounces 
which  were  wont  to  be  effused,  twenty,  or  even  more,  may  be 
evacuated.  But  it  must  be  remarked,  that  when  the  quantity 
becomes  so  excessive,  it  is  not  a  genuine  menstruous  product  that 
is  poured  out — for  this  process  is  now  accompanied  by  a  true 
hemorrhage ;  as  is  evinced  by  the  expulsion  of  coagula. 


SECT.  VII. — From  whence  the  menses  are  derived. 

From  the  last  expression  it  may  be  collected,  that  I  consider 
the  menstruous  fluid  not  as  a  pure  or  unmodified  blood :  I  shall 

1  Almost  all  the  French  writers  mention  the  influence  of  this  article  upon  the 
genital  system. 

'  A  lady  lately  informed  me  she  could,  with  the  utmost  exactitude,  tell  the  day 
and  hour  at  which  this  discharge  would  take  place.  This  was  made  known  to 
her  by  the  appearance  of  certain  feelings,  which  constantly  took  place  one  week, 
to  the  hour,  before  the  eruption  of  her  menses. 


94  HISTORY    OF    MENSTRUATION. 

therefore  state  the  reasons  for  this  belief.  1st.  Its  colour  is 
between  the  arterial  and  venal  blood,  being  less  brilliant  than  the 
former,  and  more  florid  than  the  latter.  2d.  It  never  separates 
into  parts ;  blood  drawn  or  evacuated  from  any  other  part  of  a 
healthy  body  does  separate  in  a  short  time  into  its  component 
parts.  3d.  It  never  coagulates,  though  kept  for  years :  while 
other  blood,  when  free  from  disease,  quickly  does  when  exposed 
to  the  influence  of  the  air.  4th.  Its  odour  is  remarkably  dis- 
tinct from  that  of  the  circulating  mass ;  and  it  is  less  disposed 
to  putrefaction. 

It  has  been  supposed,  because  the  menstruous  fluid  does  not 
coagulate,  that  it  contains  no  fibrine  ;  but  it  is  more  probable  that 
this  substance  has  been  deprived  of  the  power  of  coagulation  by 
being  subjected  to  the  influence  of  the  vessels  of  the  secerning 
portion  of  the  uterus.  This  opinion  is  strengthened  by  recurring 
to  the  fact,  that  the  coagulating  lymph  always  accompanies  the 
red  globules,  wherever  the  latter  may  be  found. 

The  menstruous  blood  may  therefore  be  considered  as  a  sub- 
stance differing  from  the  blood  of  the  circulating  mass  in  at  least 
two  remarkable  properties;  namely,  in  not  coagulating;  and, 
secondly,  in  not  separating  into  parts.  It  is  true,  there  are 
many,  of  high  authority,  who  declare  a  contrary  belief.  Hippo- 
crates declares  it  to  be  pure  blood ;  similar  to  that  of  a  victim, 
if  the  victim  be  in  health;  and  this  opinion  has  been  handed 
down  to  the  present  day,  without  being  challenged  by  inquiry, 
or  subjected  to  dispute.1 

If  mere  blood  were  evacuated  from  the  uterus  at  the  menstrual 
periods,  it  would  be,  strictly  speaking,  a  hemorrhage ;  but  that 
this  is  not  the  case,  the  whole  phenomena  of  this  process  seem 
to  declare.  I  have  stated,  above,  some  reasons  for  my  disbelief 
on  this  point;  and  shall  now  add,  that  had  this  operation  con- 
sisted in  the  mere  evacuation  of  unchanged  blood,  it  would  be 
attended  by  precisely  the  same  inconveniences  as  almost  always 
attend  hemorrhage  from  this  part ;  namely,  pain  of  an  alternate 
kind,  arising  from  the  contractions  of  the  uterus  to  expel  coagula 
which  always  form,  and  which  require  for  their  expulsion  the 
eiforts  of  the  uterus. 

It  may  also  be  added,  that  in  cases  of  imperforate  hymen,  the 
accumulated  menstruous  blood  constantly  remains  fluid,  though 
a  little  thickened ;  and  when  relieved  by  an  operation  from  its 
confinement,  it  is  found  to  flow  with  considerable  fre/edom  from 


1  We  believe  we  are  safe,  when  we  say,  that  a  large  majority  of  those  who 
have  written  on  the  subject  of  menstruation,  consider  the  menstrual  fluid  as  a 
pure  hemorrhagic  blood;  some  few  seem  to  agree  to  a  modification  of  this  opinion  ; 
but  this  does  not  amount  either  to  a  concession  or  denial  of  its  being  a  secretion  ; 
of  this  number,  are  Bichat  and  Broussais. 


HISTORY    OF    MENSTRUATION.  95 

the  orifice  made  for  this  purpose.     No  coagula  present  them- 
selves, as  would  be  the  case,  were  the  fluid  unchanged  blood. 

That  the  menstruous  blood  may  contain  all  the  constituent 
parts  of  common  blood,  I  do  not  mean  at  present  to  dispute,  since 
I  am  not  prepared  to  say  in  how  many  or  how  few  details  it 
may  differ,  upon  a  strict  analysis;  it  is  sufficient  for  my  present 
purpose  to  state,  that  it  must  experience  some  change  during  its 
elimination,  as  it  is  uniformly  deprived  of  the  property  of  coa- 
gulation when  in  a  healthy  state. 

This  last  circumstance,  from  its  uniformity,  must  have  a  mean- 
ing; I  have  just  stated  what  I  believe  to  be  the  probable  inten- 
tion of  this  change,  namely,  the  comfort  of  the  woman ;  but  it 
may  have  a  higher  object:  it  maybe  essential  to  the  propagation 
of  our  species.  Certain  it  is,  the  sensible  properties  of  this  eva- 
cuation differ  in  certain  individuals ;  and  it  is  found,  that  when 
this  discharge  is  very  profuse  or  very  sparing ;  when  many  coa- 
gula are  thrown  off;  when  it  is  thin  and  pink-coloured;  when 
very  black,  and  resembling,  in  some  measure,  coffee-grounds ;  or 
when  it  is  discharged  with  pain,  and  accompanied  by  a  whitish 
membrane,  the  women,  so  circumstanced,  are  constantly  barren, 
so  far  as  my  observations  have  extended. 

As  I  do  not  believe  this  discharge  to  be  a  mere  exudation 
from  the  internal  surface  of  the  uterus,  and  constituting  a  genuine 
hemorrhage,  it  is  proper  to  declare  what  I  believe  its  real  na- 
ture is.  I  look  upon  this  discharge  to  be  a  genuine  secretion, 
from  the  mucous  membrane  with  which  the  cavity  of  the  uterus 
is  lined ;  since  it  would  be  difficult  to  explain,  by  any  other  pro- 
cess than  some  peculiar  mode  of  arterial  action,  the  change  which 
evidently  is  wrought  upon  the  coagulating  lymph ;  and  we  know 
that  this  constituent  of  the  blood  is,  in  many  instances,  under 
the  immediate  influence  of  this  set  of  vessels,  as  is  proved  in 
cases  of  scurvy;  death  from  a  blow  on  the  stomach;  a  certain 
stage  of  yellow  fever ;  small  pox,  &c. 

In  these  cases,  the  blood  loses  the  power  of  coagulation  by 
some  peculiar  arterial  action ;  and  this,  sometimes,  in  a  very 
short  time.  The  same  effect  is  produced  by  the  uterine  arteries 
during  the  menstrual  process;  and  this  process  may,  with  much 
propriety,  be  termed  a  secretory  process. 

The  menstrual  fluid  has  been  considered  as  a  secretory  product 
for  very  many  years,  and  this  opinion  is  now  adopted  by  many 
of  the  physiologists  of  the  present  day:  thus,  Haller,  Bordeu, 
Sanders,  John  llunter,  &c.,  called  menstruation,  without  hesita- 
tion, a  secretion.  It  is  perhaps,  at  the  present  day,  impossible 
to  say  who  first  broached  this  doctrine.  The  credit  has  been 
given  to  each  of  the  gentlemen  just  named,  but  not  with  justice, 
as  I  shall  show  immediately. 

In  Rammazini's  "Essaisur  les  Maladies  des  Artisans,"  p.  214, 


96  HISTORY    OF    MENSTRUATION. 

we  find  the  following  passage :  "  II  y  a  tout  lieu  de  croire  que  le 
sang  des  regies  a  quelque  qualit6  maligne  et  cachee ;  et  on  lui  a 
donne  a  juste  titre  le  nom  de  secretion  et  excretion."  In  this 
passage  the  word  secretion  appears  to  be  familiarly  employed, 
and  was  the  one  most  probably  used  in  common  parlance  among 
the  medical  men  of  the  day. 

Fourcroy,  the  translator  of  this  work  from  the  Latin,  in  a 
note  to  a  part  of  the  paragraph  from  which  the  above  extract  is 
taken,  says,  "  Rien  cependant  n'etoit  plus  naturel,  sans  avoir  re- 
cours  aux  phenomenes  chymiques,  que  de  concevoir  le  flux  des 
regies,  comme  une  secretion,  qui  a  son  organe,  ses  periods  reglee, 
sa  marche  et  son  department,  ainsi  que  toutes  les  autres  secre- 
tions," p.  216. 

From  these  extracts  it  is  evident  that  neither  of  the  gentlemen 
above  mentioned  is  justly  entitled  to  the  honour  of  the  sugges- 
tion, for  the  first  edition  of  Rammazini's  work  was  published  in 
1700.  Indeed,  it  would  seem,  from  the  manner  in  which  it  is 
mentioned  in  this  work,  that  the  doctrine  was  not  new  at  that 
time;  at  least  there  is  no  claim  laid  to  originality  by  Ramma- 
zini. 

SECT.  VIII. — The  Uterus,  is  it  lined  by  a  Mucous  Membrane? 

I  consider  the  uterus  to  be  lined  with  a  membrane  of  the  mu- 
cous class,  as  taught  by  Bichat  and  others,  notwithstanding  its 
existence  has  been  lately  called  into  question.  In  examining  the 
latest  authority  on  this  subject  within  my  reach,  I  find  it  doubt- 
fully mentioned  by  Meckel,  in  his  Manuel  d'Anatomie,  as  trans- 
lated by  Jourdan  and  Breschet,  vol.  iii.  p.  611.  He  says — 

"La  face  interne  de  lamatrice  est  tapisse  par  une  membrane 
muqueuse  rougeatre,  presque  lisse,  garnie  seulement  de  villosit6s 
tres  fines,  qui  se  continue  superieurement,  et  de  chaque  cot6, 
avec  celles  des  trompes,  inferieurement  avec  celle  du  vagin. 
Dans  1'etat  frais,  cette  membrane  adhere  d'une  maniere  si  intime 
a  la  substance  fibreuse  sous-jacente,  qu'on  ne  peut  Ten  isoler, 
quoique  sa  structure  annonce  assez  qu'elle  appertient  a  la  classe 
des  membranes  muqueuses ;  mais,  avec  du  soin  et  de  precautions, 
on  parvient  a  en  detacher,  quelques  lambeaux,  apres  avoir  sou- 
mis  la  matrice  a  la  maceration." 

"Son  union  intime  avecle  reste  de  la  substance  de  la  matrice 
a  fait  revoquer  son  existence  en  doute  par  plusieurs  anatomistes."1 

1  "  C'est  I'opinion  de  Chaussier  et  de  Ribes.  Me.  Boivin  dit  aussi  n'avoir  ja- 
mais  apereju  cette  membrane  muqueuse,  et  pense  que  la  face  interne  de  la  ma- 
trice n'est  formee  que  par  1'extremite  des  vaisseaux  exhalans  qui  s'y  ouvrent. 
Une  pareille  explication  est  tres  vague,  sinon  meme  tout  a  fait  unintelligible. 
L' Analogic,  quand  il  n'y  aurait  pas  d'autre. motif  que  celui-la,  ne  permettrait  pas 
de  douter  que  la  face  interne  de  la  matrice  ne  soit  tapissee  par  une  membrane." — 
Notes  des  Traducteurs. 


HISTORY    OP    MENSTRUATION.  97 

It  is  truly  a  matter  of  surprise,  that  it  should  be  questioned 
for  an  instant,  that  the  uterus  is  lined  with  a  membrane,  and  this 
of  the  mucous  kind ;  for  neither  the  authority  of  Morgagni,  Boer- 
haave,  nor  Haller,  all  of  whom  Chaussier  has  called  to  his  aid 
to  support  the  opinion,  can  possibly  alter  the  structure  of  this 
part ;  for  a  membrane  is  obvious  to  the  eye ;  and  when  mace- 
rated, is  tangible  to  the  fingers,  and  the  nature  of  its  discharges 
proves  it  to  be  a  mucous  membrane.  It  has  been  thought  by 
some  to  be  of  the  deciduous  kind,  and  regularly  cast  off  after 
each  delivery,  or  even  after  abortions.  There  is  much  reason, 
from  the  appearance  of  this  part  after  delivery,  to  countenance 
this  opinion — it,  however,  wants  confirmation.  But  if  this  sug- 
gestion were  admitted  in  its  fullest  extent,  it  would  not  militate 
against  the  presumption  that  it  is  a  mucous  membrane.  For  this 
membrane  must  be  considered  as  possessing  a  considerable  va- 
riety of  function  under  particular  circumstances:  for  mucous 
membranes  are  made  to  throw  out,  not  only  mucus,  but  pus,  and 
even  modifications  of  these  substances. 

It  is,  in  truth,  most  intimately  connected  with  the  substance 
of  the  uterus,  and  cannot,  perhaps,  ever  be  separated  from  it  in 
the  recent  and  sound  state.  But  this  only  proves  the  closeness 
of  its  connexion,  and  not  its  non-existence.  Indeed,  this  strict 
union  strikes  me  as  highly  useful  in  the  economy  of  gestation: 
for  were  it  loosely  and  uncertainly  attached  to  the  substance  of 
the  uterus,  much  inconvenience  would  neces^rily  result  from 
the  great  distention  this  organ  undergoes  durmg  pregnancy. 

Upon  opening  an  unimpregnated  uterus,  and  viewing  the  cavity 
it  presents,  we  are  immediately  struck  with  the  smoothness  and 
polish  of  its  surface :  now,  it  may  be  proper  to  ask,  what  is  this 
whitish  and  shining  surface  which  presents  itself?  Can  it  be 
the  extremities  of  the  exhalants  of  Me.  Boivin  ?  or  the  proper  sub- 
stance of  the  uterus,  as  insisted  on  by  Chaussier?  Will  an  ar- 
rangement like  that  of  Me.  Boivin,  or  Messrs.  Chaussier  and 
Ribes,  secrete  a  mucous  fluid;  yield  a  fluor  albus;  or  render  a 
pus?  Or,  in  other  words,  will  any  other  surface,  save  a  mucous 
surface,  display  the  phenomena  of  a  confessed  mucous  membrane. 

The  existence  of  this  membrane  is  denied,  because  it  cannot 
be  separated  from  the  substance  of  the  uterus.  And  when  it  is 
urged  that  this  can  be  effected  by  maceration,  or  incipient  pu- 
trefaction, they  declare  the  separated  portion  to  be  no  mem- 
brane, but  some  accidental  concretion.  It  is  said  by  Chaussier 
and  Itibes,  that  the  membrane  which  lines  the  vagina  termi- 
nates at  the  orifice  of  the  uterus. 

The  quality  of  the  menstrual  blood  has  been  a  matter  of  much 
dispute  with  many  of  the  writers  upon  this  subject.    It  is  by  some 
considered  perfectly  innoxious,  and  by  others  as  extremely  dele- 
terious.    The  ancients  attributed  to  it  the  most  baleful  effects 
7 


98  HISTORY   OF   MENSTRUATION. 

upon  both  living  and  inanimate  matter.  Thus,  Pliny  declares  the 
approach  of  a  menstruating  woman  will  turn  new  wine  sour,  ren- 
der fruit  trees  sterile,  or  even  destroy  them ;  burn  up  the  seeds 
and  fruit  of  a  garden,  if  she  should  sit  near  them,  &c.  &c.;  while 
Fallopius,  Rodrigue  ^  Castro,  Baillou,1  &c.,  assure  us,  in  its 
natural  state,  that  it  is  perfectly  free  from  all  bad  qualities.  La 
Motte,  though  apparently  willing  to  remove  the  imputation  urged 
against  the  menstrual  blood  by  Pliny  and  others,  cannot  alto- 
gether divest  himself  of  the  prejudices  of  the  times  and  of  educa- 
tion. He  seems  disposed,  however,  to  compromise  between  the 
force  of  opposing  facts,  (which  he  confesses  daily  to  have  ob- 
served,) and  the  influence  of  names  and  of  instruction,  by  re- 
lating, with  great  naivetf,  the  following  story. 

After  having  timidly  attempted  the  refutation  of  Pliny  and 
others,  "that  the  menstrual  blood  is  most  injurious,"  he  says, 
"But  I  see  sufficient  to  make  me  apprehend  the  presence  of  a  wo- 
man in  this  situation,  especially  if  she  have  red  hair.  I  had  a 
servant  of  this  kind.  One  day  I  gave  a  breakfast  to  a  number  of 
my  friends;  white  wine  is  the  kind  which  is  usually  preferred 
upon  these  occasions;  especially  if  you  intend  to  eat  oysters ;  and 
mine  was  excellent;  and  was  drawn  by  this  servant.  My  friends 
expatiated  upon  the  goodness  of  my  wine.  The  next  day  I  break- 
fasted in  like  manner  with  one  of  the  friends  who  had  been  with 
me  ;  but  he  had  no  wine  but  red ;  I  immediately  sent  for  some  of 
my  white  wine ;  Imt  it  was  found  so  spoiled  as  to  serve  for  nothing' 
but  vinegar.  TnWsame  servant  aided  in  salting  some  pork,  which 
was  afterwards  found  to  be  spoiled ;  though  the  part  which  was 
salted  by  another  person,  in  another  cellar,  was  perfectly  good." 
He  adds,  however,  with  his  usual  candour,  "but  I  cannot  say 
whether  this  may  not  have  been  the  fault  of  the  salt."2 

It  must  be  admitted  that  this  secretion  is  acrid,  occasionally, 
and  will  leave  traces  of  its  acrimony  upon  the  parts  over  which 
it  flows ;  but  when  this  happens,  it  must  be  recollected  that  this 
discharge  is  in  a  deranged  state,  and  no  longer  a  pure  menstru- 
ous  evacuation.  This  occurs  more  frequently  towards  the  de- 
cline, than  in  the  early  part  of  life ;  and  especially  if  there  be  a 
tendency  to  cancer.  It  must,  however,  be  recollected,  that  even 
in  such  instances,  the  general  system  is  not  contaminated  in  the 
commencement  of  this  condition  of  the  uterus ;  the  acrimony  of 
the  discharge  results  from  an  altered  action  of  the  vessels  con- 
cerned in  the  process  of  elimination,  and  its  exposure  to  the  air  ; 
and  it  is  not  until  portions  of  this  discharge  are  absorbed,  or 
until  the  system  at  large  sympathizes  with  the  diseased  parts, 
that  any  evidence  of  the  uterine  affection  is  betrayed  by  the  skin 
or  other  portions  of  the  body  becoming  decomposed. 

The  idea  of  the  impurity  of  the  menstruous  blood  took  its  rise 

1  Rammazini,  p.  214.  *Traite  des  Accouchemens,  p.  57. 


HISTORY    OP    MENSTRUATION. 

from  the  supposition  that  this  discharge  was  intended  to  relieve 
the  woman  from  certain  noxious  humours  generated  in  her  body 
from  her  sedentary  habits,  as  well  as  other  causes.  Hence,  so 
much  dread  was  entertained,  when  this  evacuation  was  inter- 
rupted from  any  other  cause  than  pregnancy.  But  no  alarm 
was  excited  when  this  flux  was  arrested  by  gestation;  as  it  was 
then  employed,  they  said,  for  the  purposes  of  the  foetus,  and  they 
appear  willing  to  think  the  embryo  cannot  be  injured  by  it. 

This  opinion  they  thought  was  supported  by  the  appearance  of 
certain  eruptions  upon  various  parts  of  the  body  when  this  dis- 
charge was  suppressed,  and  which  yielded  only  to  such  reme- 
dies as  restored  this  evacuation.  But  this  fact,  at  the  present 
day,  would  be  explained  upon  very  different  views  of  the  animal 
economy ;  and  will  no  longer  serve  to  support  the  notion  of  the 
deleterious  effects  of  suppressed  menses.  Indeed,  we  may  with 
much  plausibility  suppose  that  the  dogma  of  the  impurity  of  the 
menstruous  blood  originated  in  a  medico-political  necessity,  in 
the  warm  climate  which  first  gave  rise  to  the  suggestion.  Moses 
was  fully  aware  of  the  consequences  of  the  want  of  cleanliness 
among  his  people;  and  no  stranger  to  the  inconveniences  which 
arise  from  a  neglect  of  it :  he  therefore  looked  upon  women, 
during  the  period  of  their  catam'enial  flow,  as  impure,  and  that 
they  would  remain  so,  until  they  were  well  absterged;  hence  his 
pointed  directions  and  observances  at  this  period.  To  ensure 
success  to  this  scheme  of  cleanliness,  the  aid  of  medical  specu- 
lation was  required,  and,  most  probably,  it  was  not  reluctantly 
obtained.  The  ancients,  in  a  word,  were  scrupulously  exact 
upon  this  point;  for  they  considered  the  health  of  the  woman 
materially  connected  with  the  menstrual  discharge,  and  looked 
upon  repose  of  body  and  tranquillity  of  mind  as  essential  to  the 
best  performance  of  this  secretion — they  therefore  forbade  their 
females  to  appear  in  public,  during  its  flow,  lest  agitation,  or 
over-exertion,  should  derange  this  natural  and  important  func- 
tion ;  and  to  ensure  compliance,  urged  the  morbid  nature  of  the 
menstruous  fluid.  Indeed  they  went  so  far,  as  to  even  forbid 
the  employment  of  the  ban.dage,  now  in  almost  universal  use 
with  females  who  are  menstruating,  because  they  declared  it 
prevented  the  immediate  flow  of  the  menses,  and  thus  permitted 
this  fluid  to  accumulate,  and  stagnate  in  the  vagina. 

It  was  also  supposed  that  hemorrhages  from  other  parts  of  the 
body  must  be  a  necessary  consequence  of  the  uterus  failing  to 
secrete  the  menstruous  blood ;  and  we  find,  in  books  on  medicine, 
very  many  instances,  purporting  to  be  illustrative  of  this  hypo- 
thesis. I  am  not  prepared  to  say  that  such  a  thing  never  has 
existed;1  but  I  can  with  the  most  entire  confidence  declare  I 

1  Gardien  relates  a  curious  case,  upon  the  authority  of  M.  Brule,  which  he 
considers  as  a  proof  of  the  diversion  of  the  menstrual  action,  but  which  I  catmot 


100  HISTORY    OF    MENSTRUATION. 

never  witnessed  such  examples;  and  when  they  occur  they  must 
be  considered,  if  entitled  to  any  weight,  but  as  exceptions  to  the 
rule.  Have  not  instances  occurred  of  foetuses  being  found  in 
the  ovaria  of  virgins? 

At  the  present  day,  I  believe,  no  one  will  imagine,  that  he  ob- 
serves a  woman's  health  to  be  worse,  as  a  regular  occurrence,  as 
she  approaches  the  period  for  her  catamenial  flow ;  nor  think  that 
he  sees  an  improvement,  after  this  period  has  passed  over ;  yet 
it  would  seem  essential  to  the  support  of  this  conjecture,  that  both 
one  and  the  other  should  happen.  Nor  is  there  much  reliance 
to  be  placed  upon  the  existence  of  the  "menstrual  fever  "  of  the 
older  writers,  though  supported  by  the  later  authority  of  Bordeu. 
That  fever  may  occasionally  be  perceived  at  such  periods,  I  have 
no  reason  to  deny;  but  that  it  is  an  attendant  upon  this  discharge, 
as  one  of  its  phenomena,  I  have  much  reason  to  doubt.  When 
this  opinion  arose,  itowas  the  order  of  the  day  to  be  minute ;  and 
an  accidental  circumstance  was  recorded  for  an  essential  cha- 
racter. What  shall  we  say  of  women  who  have  never  menstru- 
ated ?  Do  they  enjoy  equal  health  with  those  who  do  ?  Are  they 
capable  of  fecundation?  As  regards  our  own  experience,  we 
would  answer  each  of  these  questions  in  the  negative — but  Frank 

but  regard  as  a  periodical  hemorrhage ;  and  altogether  analogous  to  the  bleeding 
hemorrhoids,  which,  in  females,  frequently  observe  as  much  regularity  when  the 
menses  are  regular  as  when  they  may  be  absent. 

"First  deviation. — The  menses  were  suppressed  in  a  young  girl,  whose  life 
had  been  a  series  of  illnesses  up  to  that  moment.  She  became  regular  after  this  : 
for  six  months  the  discharge  was  evacuated  from  little  wounds  in  the  legs  occa- 
sioned by  the  breaking  of  some  small  vesicles. 

"  Second  deviation. — There  appeared  on  the  left  arm  some  vesicles  or  pimples, 
(boutons,)  which  yielded  blood  at  the  menstrual  period  during  a  year. 

What  analogy  is  there  between  the  structure  of  these  "  vesicles  or  pimples," 
(boutons)  and  that  of  the  uterus  which  yields  the  menstrual  fluid  ?  None  whatever ; 
the  blood,  in  such  instances,  uniformly,  I  believe,  coagulates.  These  changes,  if 
they  take  place,  must  be  regarded  in  some  as  compensating  discharges,  rather 
than  as  vicarious. 

"  Third  deviation. — This  was  succeeded  by  a  whitlow  on  the  left  thumb,  and 
a  chap  upon  the  first  phalanx;  and  at  the  end  of  two  months  the  menstrual  blood 
flowed  periodically  from  this  part  for  six  months. 

"Fourth  deviation. — The  girl  was  now  attacked  by  an  erysipelas  in  the  face 
and  the  left  eye,  which  terminated  by  two' openings,  one  at  the  angle  with  the 
nose,  and  the  other  in  the  middle  of  the  upper  eyelid;  these  two  openings  yielded 
an  evacuation  periodically  for  two  years ;  it  then  ceased  from  these  parts,  to  be 
voided  by  the  left  thumb. 

"Fifth  deviation. — An  erysipelas  now  showed  itself  upon  the  abdomen,  at- 
tended by  great  itching;  the  navel  was  very  painful,  and  for  five  months  the  blood 
flowed  regularly  from  this  part  at  each  menstrual  period. 

" Sixth  deviation. — A  slight  accident  happened  to  the  left  internal  malleolusof 
the  ankle,  and  the  blood  flowed  regularly  from  this  part  for  four  months. 

"Seventh  deviation. — An  acute  pain  was  felt  in  the  left  ear;  a  discharge  took 
place  from  this  part  for  two  months. 

"  When  the  blood  did  not  flow  from  any  determinate  spot,  it  would  vent  itself 
by  a  hemorrhage  from  the  nose,  or  from  the  stomach  by  vomitings  preceded  by 
headach  and  giddiness." — Traite  Complet.  d' Accouchemens ,  $rc.  Vol.  I.  p.  239. 


DERANGED   MENSTRUATION,  101 

entertains  a  different  opinion  upon  each  of  these  points.  He 
says,  "  We  rarely  meet  with  women  who  have  never  menstruated ; 
however,  there  have  been  such  instances,  and  such  women  have 
enjoyed  the  most  perfect  health ;  a  strong  constitution ;  they 
were  even  fruitful."  Med.  Pract.  Tom.  3,  p.  382. 

To  these  observations,  we  must  say,  that  they  must  have 
greater  confirmation,  before  they  can  be  relied  upon  as  facts — 
for  the  reverse  has  been  the  constant  result  in  the  few  cases 
which  have  fallen  under  our  own  notice.  Nor  is  it  very  difficult 
to  understand,  that  this  must  be  the  case ;  since  it  clearly  proves, 
that  when  this  evacuation  does  not  take  place,  it  must  be  owing 
to  some  decided  imperfection  in  some  one  part,  at  least,  of  the 
genital  system ;  and  that,  for  the  purposes  of  propagation,  we 
are  of  opinion  the  most  healthy  condition  of  these  organs  is  re- 
quired. And  we  think  that  Frank  himself  yields  the  point  com- 
pletely, by  his  attempt  to  explain  it.  For  he  adds,  immediately 
after  what  is  above  quoted,  "  If  we  meet  with  a  great  number  of 
women  thus  situated,  and  who  do  not  conceive,  we  must  not  ac- 
cuse a  defect  of  menstruation  for  it,  but  a  vicious  conformation 
of  the  genital  parts."  Ib. 


CHAPTER  VI. 


DERANGED   MENSTRUATION. 

AFTER  giving  the  history  of  menstruation,  it  would  seem  pro- 
per we  should  furnish  an  account  of  the  various  derangements 
to  which  this  function  is  liable,  and  the  mode  of  treating  them. 

The  derangements  to  which  this  discharge  is  liable  are  as 
follow : — 

1st.  Its  too  tardy  appearance. 

2d.  Its  interruption  after  having  been  established,  commonly 
called  the  suppression  of  the  menses. 

3d.  Its  excess  of  quantity. 

4th.  Menorrhagia. 

5th.  Dysmenorrhoea,  or  painful  menstruation. 

6th.  Its  irregularity  towards  the  decline  of  life. 

'    '      -.}.!'.'    •••-  I  '•  '  HOOT1"  » 

SECT.  I. — 1.  Of  the  tardy  Appearance  of  the  Menses. 

In  our  history  of  menstruation  we  have  shown  that  this  pro- 
cess is  more  regulated  by  the  condition  of  the  system  than  by 


102  TARDY  APPEARANCE   OP  THE   MENSES. 

the  age  of  the  female :  and  that  though  the  climate  and  manners 
of  each  portion  of  the  globe  exert  an  influence  upon  the  human 
constitution,  yet  that  this  influence  is  constantly  observed  to  ma- 
nifest itself  in  the  more  early  or  tardy  development  of  the  geni- 
tal organs.  This  being  the  case,  the  period  of  puberty,  or  that 
period  at  which  the  human  female  is  capable  of  propagating  her 
species,  and  of  which  condition  the  menstrual  discharge  is  the 
sign,  will  arrive  at  different  periods  of  female  life  ;  but  never, 
until  the  organs  destined  to  furnish  this  evacuation  are  suffi- 
ciently developed,  to  meet,  and  overcome,  all  the  ordinary  con- 
tingencies of  impregnation  and  of  labour. 

"  The  retardation  of  puberty  retards,  also,  the  development 
of  the  mental  faculties ;  but  preserves  energy  and  freshness  to 
the  sentiments,  and  developes  vigorous  bodies ;  and  that  if  in 
woman  this  state  is  prolonged  after  the  ordinary  periods,  she 
appears  to  approximate  to  man,  both  in  some  of  his  tastes  and 
in  some  of  his  characteristics."  (Walker  on  Intermarriages.) 

It  will  therefore  follow,  as  a  general  rule,  that  climate  will  de- 
termine, in  the  female  constitution,  a  period  for  the  development 
of  these  organs,  and  consequently  for  the  appearance  of  the 
menses,  in  each  particular  portion  of  the  globe.  This  being  the 
case,  a  general  period  is  established,  at  which  this  evacuation 
may  be  looked  for;  and  this  is  so  nearly  constant,  (cseteris  pafi- 
bus,)  that  any  deviation  in  this  respect  is  looked  upon  as  a  state 
of  derangement,  if  not  of  disease;  hence,  the  surprise  that  is  al- 
ways expressed,  when  this  evacuation  anticipates  the  common 
period;  and  the  solicitude  when  it  does  not  take  place  at  the 
ordinary  time. 

In  consequence  of  this  general  law, — a  law  established  by  cli- 
mate and  manners, — many  vulgar  errors  have  arisen,  which  have 
too  successfully  exerted  an  influence  upon  the  conduct  of  those 
who  may  have  charge  of  females  at  this  critical  and  interesting 
period  of  life. 

The  average  period  for  the  first  appearance  of  the  menses  may 
be  between  the  fourteenth  and  fifteenth  year  in  this  country. 
When  they  fail  at  this  time,  much  anxiety  is  evinced  on  the  part 
of  the  friends  of  the  girl  so  circumstanced ;  and  every  indisposition 
with  which  she  may  be  attacked  is  sure  to  be  attributed  to  this 
cause.  In  the  hope  of  provoking  the  menses,  now  due,  as  they 
suppose,  from  the  age  of  the  girl,  she  is  almost  always  condemned 
to  medical  discipline,  and  but  too  frequently  injured  by  submit- 
ting to  its  rules.  Nothing,  perhaps,  would  be  more  difficult  to 
overcome  than  the  prejudice  of  the  necessity  of  this  discharge, 
at  a  certain  period  of  female  life,  and  this  period  determined  by 
the  number  of  years  which  have  passed.  Women,  upon  this 
subject,  are  but  too  often  incorrigibly  wrong-headed;  and  we  are 
sometimes  obliged  to  yield,  for  the  patient's  sake,  an  appearance 


TARDY    APPEARANCE    OP    THE    MENSES.        103 

of  acquiescence.  In  many  instances,  did  we  attempt  to  convince 
them  of  their  error,  it  would  not  only  be  labour  lost,  but  what  is 
worse,  would  too  often  deliver  the  patient  over  to  the  discipline 
of  some  rapacious  quack,  or  some  ignorant  practitioner  of  medi- 
cine. 

The  lapse  of  a  certain  number  of  years  is  not  all  that  is  re- 
quired that  the  menses  may  make  their  appearance ;  the  uterus 
and  ovaria  must  be  developed,  and  be  in  good  health,  if  I  may 
so  express  myself,  before  this  discharge  will  show  itself;  and  this 
condition  of  the  genital  system  is  always  indicated  by  corre- 
sponding changes  in  certain  other  portions  of  the  system — there 
must,  and  will  be,  evidences  of  womanhood,  before  this  event 
can  happen;1  and  when  these  are  absent,  the  girl  should  never 
be  tortured  by  the  class  of  remedies  called  emmenagogues. 

There  seem  to  be  four  conditions  of  the  female  system,  in 
which  the  menses  are  tardy  in  their  appearance :  a,  where  there 
is  little  or  no  development  of  the  genital  organs ;  5,  where  this  is 
taking  place  very  slowly;  c,  where  the  development  is  inter- 
rupted by  a  chronic  affection  of  some  other  part ;  d,  where  the 
most  perfect  development  has  taken  place,  yet  they  do  not  ap- 
pear. The  management  of  each  of  these  conditions  is  different 
— I  shall,  therefore,  treat  of  them  in  order. 

Condition  a,  or  where  there  is  little  or  no  development  of  the 
genital  organs.  This  condition  of  the  system  is  easily  detected 
by  the  absence  of  all  the  signs  which  should  characterize  puber- 
ty— the  breasts  do  not  swell ;  nor  are  there  capilli  always  on  the 
pubes.  In  a  girl  thus  circumstanced,  who  otherwise  is  in  good 
health,  it  would  be  worse  than  idle,  it  would  be  cruel  and  disho- 
nest, merely  because  she  had  attained  her  fourteenth  or  fifteenth 
year,  to  subject  her  to  medical  rule,  or  to  goad  her  system  by 
stimulating  emmenagogues.  In  such  a  case,  if  the  mother  or 
friends  are  rational,  and  to  be  trusted,  we  may  honestly  give  our 
opinion  of  the  entire  insufficiency  of  medicine  to  produce  the  de- 
sired end.  We  should  explain,  so  far  as  we  can,  the  nature  of 
the  function  of  menstruation,  and  of  the  prerequisites  to  this  dis- 
charge ;  and  attempt  to  produce  on  their  minds  the  important 
conviction,  that  time,  under  proper  circumstances,  is  all  that  is 
required  to  effect  the  anxiously  hoped  for  change. 

I  have  encountered  many  such  cases — with  some  I  have  suc- 
ceeded in  bringing  the  friends  to  my  opinion ;  in  others  I  have 
not  been  so  fortunate ;  the  latter  may  be  divided  into  two  classes 
— the  one,  though  not  convinced  by  our  reasoning,  dare  not  openly 

1  I  have  lately  seen  three  instances  which  contradict  this  rule— in  neither  of 
which  was  there  the  slightest  development  of  the  mammae;  but  in  each  of  these 
cases  there  was  a  diseased  spine.  Whether  this  condition  of  the  spine  has  any 
influence  upon  the  appearance  of  the  menstrual  evacuation,  remains  to  be  proved. 
See  page  85. 


104        TARDY    APPEARAN-CE   OF    THE    MENSES. 

.bid  defiance  to  it,  because  they  fear  responsibility  ;  and  thus 
yield  a  reluctant  acquiescence.  The  second,  confident  in  their 
own  judgment,  will  sometimes  act  upon  it,  to  the  imminent  risk, 
if  not  to  the  destruction  of  the  poor  girl,1  who  maybe  the  object 
of  their  solicitude. 

With  the  latter,  when  importunate,  we  should  use  a  tempo- 
rizing plan  ;  and  by  the  administration  of  some  entirely  inert  me- 
dicine, gain  time,  and  save  the  patient  from  permanent  ill 
health,  or  an  untimely  grave.  I  but  too  often  call  to  mind,  with 
bitter  recollection,  the  fate  of  a  most  amiable  and  interesting 
young  creature,  for  whom  I  was  requested  to  prescribe  for  the 
expected  menses,  but  who  had  not  one  mark  which  would  justify 
an  interference;  and,  especially,  as  she  was  in  perfectly  good 
health — she  was  fifteen,  it  is  true  ;  and  this  was  all  that  could  be 
urged  by  the  mother  in  favour  of  an  attempt  to  "  bring  down  her 
courses."  I  relied  too  much  upon  the  good  sense  of  her  anxious 
parent;  and  freely  explained  myself  to  her — she  left  me  appa- 
rently satisfied  with  my  reasoning ;  and  I  heard  nothing  of  the 
poor  child  for  six  months  :  at  the  end  of  this  time  I  was  suddenly 
summoned  to  attend  her,  as  she  was  said  to  be  alarmingly  ill. 

When  I  saw  her,  she  was  throwing  up  blood  in  considerable 
quantities  from  the  lungs ;  she  died  a  few  days  after,  from  the 
excess  of  this  discharge.  The  distracted  mother  told  me,  that 
though  she  appeared  satisfied  with  what  I  had  said,  when  she  left 
me,  she  was  convinced  I  was  wrong ;  and  that  her  daughter's 
health  required  the  immediate  establishment  of  the  menstrual 
evacuation.  With  this  view,  she  determined  upon  the  trial  of  a 
medicine  of  much  celebrity  in  similar  cases,  vended  by  a  quack. 
She  procured  it,  and  gave  it  according  to  directions  :  in  a  few 
days  her  daughter  became  feverish,  lost  her  appetite,  and  fre- 
quently vomited;  her  strength  failed,  and  after  a  short  time  she 
was  confined  to  her  bed— she  called  upon  the  "Doctor,"  and 
made  known  to  him  the  condition  of  her  daughter  ;  he  encouraged 
her  to  persevere,  and  told  her  that  the  fever,  &c.,  was  an  effort 
nature  was  making  for  the  end  proposed;  she  persevered,  fatally 
persevered ;  for  in  a  few  days  more  she  lost  her  lovely  and  only 
daughter.  I  examined  the  medicine  which  had  been  exhibited ; 
it  proved  to  be  the  oil  of  savin. 

Condition  b,  or  where  the  development  is  taking  place  slowly. 
This  condition  is  known  by  the  partial  alteration  the  mammae 
have  undergone;  by  some  expansion  of  body;  and  the  protrusion 
of  capilli  on  the  pubes.  The  general  health  sometimes  suffers 
slightly  ;  especially  if  the  girl  has  passed  the  fifteenth  year,  and 
grows  rapidly— she  is  assailed  by  a  train  of  nervous  symp- 
toms, as  they  are  called :  such  as  palpitation  of  the  heart,  ring- 

1  Bread  pills  are  an  excellent  succedaneum,  they  interfere  with  nothing. 


TARDY  APPEARANCE    OF    THE   MENSES.  105 

ing  in  the  ears,  headach ;  a  temporary  diminution  of  strength 
upon  any  sudden  exertion,  loss  of  appetite,  or  a  whimsical  state 
of  it,  &c. 

This  condition  is  not  unfrequently  accompanied  by  fluor  albus ; 
and  when  it  is,  more  particularly  deserves  notice.  This  case 
merits  attention,  when  the  health  appears  to  suffer;  hut  must 
not  be  meddled  with  when  it  does  not. 

Our  exertions  in  favour  of  such  patients  should  tend  to  the 
invigoration  of  the  system  in  general,  and  the  development  of 
the  uterine  system  in  particular.  The  first  should  be  attempted, 
1st,  by  the  establishment  of  a  regular  course  of  exercise: — such 
as  riding  on  horseback,  when  practicable;  walking  in  proper 
weather ;  skipping  the  rope  within  doors,  when  the  weather  will 
not  permit  exercise  abroad;  dancing  moderately,  and  with  strict 
regard  not  to  become  over-heated,  and  cooling  too  suddenly; 
2dly,  by  proper  attention  to  dress;  wearing  flannel  next  to  the 
skin  in  cold  weather,  and  properly  protecting  the  feet  and  legs 
against  cold;  carefully  avoiding  damp  and  wet  places,  and  par- 
tial streams  of  cold  air,  especially  when  warm ;  3dly,  by  a  diet 
of  easily  digested  substances,  both  of  the  animal  and  vegetable 
kind ;  avoiding  all  stimulating  drinks,  such  as  wine,  spirits  or 
beer,  &c.,  under  the  specious  pretext  of  their  being  strengthen- 
ing. 

The  second  must  be  accomplished  by  such  medicines  as  have 
a  direct  or  indirect  action  upon  the  uterus  itself;  of  the  direct, 
the  tincture  of  cantharides  appears  to  be  the  most  efficient,  and 
should  be  preferred  to  all  others  when  leucorrhoea  attends  ;  thirty 
drops  should  be  given  three  times  a  day,  until  this  discharge 
ceases.  We  may  gradually  increase  the  dose,  should  the  com- 
plaint be  obstinate;  for  it  is  of  primary  importance  that  it  be 
removed;  for  we  need  scarcely  look  for  the  catamenia,  while 
this  remains  in  any  force — leucorrhoea  is  a  kind  of  local  deple- 
tion, and  prevents  that  congestion  of  the  uterus  so  favourable  to 
development,  and  the  production  of  the  catamenial  discharge. 
The  parts  should  be  regularly  bathed  every  day  with  warm  wa- 
ter; especially  during  the  continuance  of  the  fluor  albus. 

Of  the  indirect  kind,  aloes  seems  to  be  the  more  certain — the 
influence  of  this  drug  upon  the  uterus  has  been  very  long  ac- 
knowledged, and  was  much  extolled  for  this  purpose  by  Mor- 
gagni  and  his  contemporaries — it  should  be  given  in  very  small 
doses,  and  perseveringly  continued;  this  medicine  is,  perhaps, 
preferable  to  the  tinct.  eanth.  where  leucorrhcea  does  not  attend ; 
the  following  is  the  formula  I  generally  employ: — 

R.  Gum  aloe.  sue.  gss. 
Pulv.  Rhaei.  opt.  3J. 
Ol.  Caryoph.  gut.  iv. 
Sapo  Venet.  gr.  viij. 
Syr.  Rhaei.  q.  s. — M.  f.  pil.  be. 


TARDY   APPEARANCE   OF   THE   MENSES. 

One  of  these  to  be  given  every  night,  night  and  morning,  or 
every  other  night,  as  they  may  affect  the  bowels — the  object  is 
to  keep  the  bowels  free,  but  not  purged.  This  prescription  is  a 
remarkable  instance  of  the  power  of  combination ;  for  the  very 
small  dose  just  recommended  will  sometimes  act  with  great 
force  upon  the  bowels — so  much  so,  sometimes,  as  to  oblige  us 
to  reduce  the  above  quantity  one  half.  The  same  regard  must 
be  paid,  at  the  same  time,  to  air,  exercise,  and  diet,  as  just  re- 
commended. 

Condition  c,  or  where  this  development  is  prevented  by  a  chro- 
yc  affection  of  some  other  part.  The  condition  is  readily  de- 
tected by  the  presence  of  any  such  disease  as  may  be  capable 
of  interrupting  this  discharge,  after  it  has  been  thoroughly  well 
established;  such  as  phthisis  pulmonalis;  chronic  inflammation 
of  the  liver,  or  spleen ;  dropsy,  &c.  Under  the  existence  of 
either  of  these  diseases,  the  menses  will  almost  always  be  sus- 
pended ;  because  it  will  certainly  interrupt  the  development  of 
the  organs  essential  to  the  formation  of  this  discharge,  however 
favourably  this  expansion  may  have  commenced. 

This  case  constantly  exposes  the  physician  to  the  importuni- 
ties of  the  friends  of  the  patient,  for  something  "to  bring  down 
the  menses;"  it  is  in  this  case,  of  all  others,  that  they  are  per- 
suaded nothing  more  is  wanted  to  re-establish  health.  The  phy- 
sician must  here  conceal  his  real  sentiments;  for,  however  con- 
vinced he  may  be  of  the  inefficacy  of  remedies  for  this  purpose, 
he  must  not  say  so,  if  he  regard  the  welfare  of  his  patient.  For 
no  reasoning  will  convince  them  that  the  disappearance  of  the 
catamenia  depends  upon  the  diseased  condition  of  some  other 
part  of  the  body ;  and  consequently,  that  until  this  be  removed, 
their  reappearance  is  not  to  be  expected.  Indeed,  the  attempt 
would  be  mischievous ;  for  the  patient  would  most  probably  be 
taken  from  his,  and  consigned  perhaps  to  worse  hands.  He 
should,  however,  declare  to  the  friends  of  the  patient,  that  this 
circumstance,  (the  absence  of  the  menses,)  has  been  duly  weighed, 
and  will  influence  his  prescriptions. 

In  such  cases,  no  prescription  can  be  availing,  but  that  calcu- 
lated to  remove  the  original  disease ;  and  of  the  diseases  which 
may  interrupt  the  menstrual  action,  it  is  not  our  immediate  pro- 
vince to  speak,  as  they  are  not  peculiar  to  females. 

It  is  true,  however,  that  the  long-continued  suppression  of  the 
menses  may  seriously  involve  other  viscera  than  the  uterus ;  and 
their  cure,  when  thus  implicated,  may  depend  upon  the  restora- 
tion of  this  discharge ;  but  when  this  is  the  case,  it  constitutes 
the  chronic  idiopathic  suppression  of  the  catamenia.  A  want  of 
attention  to  these  different  states  of  dysmenorrhoea,  that  is,  whe- 
ther they  be  idiopathic  or  symptomatic,  has  led  to  an  empirical 
mode  of  treatment. 


TARDY    APPEARANCE    OF    THE    ME'NSES.  107 

Condition  d,  or  when  the  most  perfect  development  has  taken 
place,  but  the  menses  do  not  make  their  appearance.  This  con- 
dition is  easily  known  by  the  girl  having  all  the  outward  signs 
of  womanhood ;  the  menses  are  all  that  is  wanting  to  complete  her 
title  to  it,  and  fit  her  for  the  duties  she  is  destined  to  fulfil. 
This  case  is  sometimes  attended  with  fluor  albus;  when  it  is,  it 
must  be  treated  as  recommended  above.  At  other  times,  there  is 
a  manifestation  of  an  attempt  by  the  uterus  to  produce  the  dis- 
charge; this  is  known  by  a  pain  in  the  back,  hips,  and  loins, 
with  a  sensation  of  fulness  in  the  pelvis,  attended  sometimes  with 
a  forcing  or  bearing  down.  These  symptoms  sometimes  recur 
periodically;  and  may  even  be  attended  by  a  serous  discharge 
from  the  vagina,  resembling  whites.  The  tinct.  canthar.,  as  re- 
commended above,  will  rarely  fail  to  produce  the  discharge,  if 
given  steadily  for  two  or  three  weeks ;  or  the  madder  may  be 
given,  especially  if  the  period  for  the  return  of  the  pains  just 
spoken  of,  be  near  at  hand.  Indeed,  this  seems  to  be  the  only 
period  at  which  this  substance  is  more  decidedly  useful  than  any 
other  of  the  emmenagogue  medicines :  it  acts  at  times  so  prompt- 
ly, as  almost  to  call  in  doubt  its  agency;  but  repeated  success, 
under  such  circumstances,  has  convinced  me  of  its  efficacy.1 
From  its  possessing  no  general  stimulating  property,  it  becomes 
very  valuable  in  cases  of  great  irritability  of  the  system,  or  where 
there  may  be  slight  febrile  paroxysms ;  for  it  seems  to  be  a  law 
of  the  animal  economy,  to  institute  fever,  whenever  strength  is 
considerably  impaired;  hence,  we  almost  always  see  it  after 
wasting  discharges  of  every  kind. 

I  have  found  that  a  strong  decoction  of  this  wood  is  of  equal 
efficacy  with  the  substance,  and  is  much  more  easily  taken.  A 
pint  of  boiling  water  is  directed  to  be  poured  upon  an  ounce  of 
finely  powdered  madder  and  a  scruple  of  bruised  cloves ;  and 
then  to  be  gently  simmered  for  fifteen  minutes ;  when  cool,  strain 
off  and  give  a  wine-glassful  every  three  hours.  I  have  lately 
had  a  case  of  this  kind,  where  the  madder  succeeded  most 
promptly.  This  case  rarely  gives  much  trouble,  unless  the  in- 
terruption has  been  occasioned  by  imprudent  exposure  to  wet  or 
cold:  in  this  instance,  it  must  be  treated  as  an  obstruction. 

A  remarkable  case  of  the  non-appearance  of  the  menses  was 
lately  under  the  care  of  my  friend  Dr.  Physick  and  myself.  A 
lady  of  thirty  years  of  age  had  the  usual  concomitants  of  pu- 
berty at  the  ordinary  age;  these  signs,  however,  were  not  fol- 
lowed by  the  catamenial  flow,  though  periodical  pain  in  the  hips, 
loins,  abdomen,  particularly  in  the  region  of  the  uterus,  nurnb- 

'  Dr.  Schonlein,  late  Professor  at  Wurzburg,  asserts  that  ten  grains  of  aloes, 
dissolved  in  a  small  quantity  of  warm  water,  and  thrown  into  the  rectum,  at  the 
period  when  catamenia  should  appear,  is  more  effectual  than  any  other  emmena- 
gogue. Amer.  Jour,  of  Med.  Sciences,  for  Feb.  l«36. 


108  TARDY    APPEARANCE    OF    THE    MENSES. 

ness  of  the  thighs,  &c.,  seemed  to  promise  it  would  be  so.  In 
this  situation  this  young  lady  has  remained  from  the  time  of  pu- 
berty to  her  present  age.  Previously  to  my  seeing  her  she  had 
tried,  without  the  least  benefit,  all  the  known  emmenagogues ;  as 
her  sufferings  were  severe,  and  so  long-continued,  several  medi- 
cal gentlemen  were  consulted  previously,  and  so  effectually  were 
all  the  established  remedies  tried,  that  I  was  left  almost  without 
resource.  On  examining  her  per  vaginam,  nothing  faulty  could 
be  discovered  about  the  uterus. 

The  only  thing  that  suggested  itself,  as  a  possible  remedy,  was 
to  pass  a  flexible  catheter  into  the  cavity  of  the  uterus,  under  a 
hope  that  something  in  the  neck  of  this  organ  might  obstruct  the 
flow  of  perhaps  accumulated  menses.  This  suggestion  was  ac- 
cordingly acted  upon ;  and  the  extremity  of  a  catheter  was  passed 
an  inch  and  a  half  through  the  neck  of  the  uterus.  The  with- 
drawing of  the  instrument  was  not  followed  by  a  discharge  of 
any  kind;  and,  consequently,  our  hopes  were  immediately  de- 
stroyed, and  our  patient  nowise  relieved.  She  had  never  been 
troubled  with  leucorrhcea,  or  any  other  discharge  from  the  vagi- 
na. This  case  we  looked  upon  as  not  less  ambiguous  than  hope- 
less. The  sufferings  of  this  patient  were  great ;  the  abdomen, 
during  the  periods  of  pain,  was  very  tender  to  the  touch,  and  a 
little  distended ;  a  considerable  hardness  was  felt  immediately  over 
the  region  of  the  pubes ;  but  no  circumscribed  tumour,  like  the 
distended  uterus,  could  be  discovered.  This  case  is  remarkable 
for  several  of  its  circumstances :  1st,  there  is  every  outward  ma- 
nifestation of  the  development  of  its  genital  system;  2dly,  at 
every  return  of  the  period  at  which  this  discharge  should  take 
place,  there  is  pain  and  other  symptoms  which  commonly  an- 
nounce this  discharge  to  be  at  hand,  when  not  regularly  estab- 
lished; 3dly,  as  far  as  an  examination  per  vaginam  could  ascer- 
tain, there  was  no  defect  in  the  uterus  itself.  In  this  case,  the 
most  probable  conjecture  I  can  make  is,  that  there  is  an  anato- 
mical defect  in  the  secreting  surface  of  the  uterus  itself;  and 
that  the  pains  which  are  endured  at  each  returning  four  weeks, 
may  be  owing  to  the  plethoric  or  engorged  state  of  this  organ, 
and  which  is  not  relieved,  as  in  common,  by  the  secretion  of  the 
menstrual  fluid. 

In  a  very  recent  work  on  the  practice  of  physic,  by  Dr.  Mack- 
intosh, Vol.  II.  p.  346,  we  find  two  or  three  cases  strongly  resem- 
bling the  one  just  related,  and  which  were  relieved  by  means 
similar  to  that  recommended,  or  rather  employed  in  that  case, 
and  may  be  regarded  as  instances  of  amenorrhcea  arising  from 
an  imperfect  or  imperforate  state  of  the  os  uteri.  It  may  not  be 
amiss  to  direct  the  attention  of  the  reader  to  a  remarkable  circum- 
stance connected  with  the  history  of  these  cases ;  namely,  that 
there  was  no  collection  of  menstruous  blood  in  the  uterus,  and 


TARDY    APPEARANCE    OF    THE    MENSES.  109 

that  the  menstrual  secretion  did  not  appear  to  take  place  until 
after  the  perforation  of  the  os  tincse.  Is  this  a  uniform  occur- 
rence in  similar  cases  ?  Does  menstrual  secretion  require,  as  a 
sine  qua  non,  an  outlet  for  its  production?  We  think  not,  as 
has  been  asserted — for  large  accumulations  have  taken  place  (as 
in  imperforate  hymen)  and  we  do  not  see  what  connexion  a  want 
of  outlet  can  have  in  the  menstrual  secretions. 

"A  young  woman,  aged  twenty-two,  came  from  the  country 
to  consult  Dr.  J.  A.  Robertson,  who  sent  her  to  me  in  the  be- 
ginning of  the  winte*  of  1826.  I  collected  the  following  particulars 
from  herself  and  a  female  friend  who  accompanied  her ;  that  the 
menstrual  discharge  had  not  yet  appeared ;  that  she  had  always 
been  healthy  till  she  reached  the  age  of  sixteen,  from  which  pe- 
riod her  health  began  to  suffer,  and  since  which  she  has  regularly 
complained  every  month  of  pains  in  the  back  and  loins,  together 
•with  a  sense  of  weight  and  bearing-down  in  the  passages.  For 
some  time  her  sufferings  were  slight,  and  she  was  still  able  to  per- 
form her  duties  as  a  servant,  but  for  the  last  two  years  she  has 
become  comparatively  weakly  and  emaciated,  and  has  not  known 
what  it  is  to  enjoy  a  day's  ease;  and  she  stated,  that  she  would 
readily  submit  to  any  thing  which  might  cure  her.  The  girl  ap- 
peared to  be  above  the  middle  stature,  the  mammae  were  unde- 
veloped, she  was  of  an  awkward  shape,  and  indeed  her  appear- 
jpce,  colour  of  skin,  and  sound  of  voice,  were  rather  masculine. 
Her  abdomen  was  not  tumid,  but  I  was  told  it  was  occasionally 
swollen,  particularly  after  meals.  She  seemed  to  be  of  a  nervous 
temperament,  and  was  exceedingly  shy  and  timid.  Upon  exami- 
nation, my  fingers  passed  readily  into  the  vagina,  and  the  uterus 
was  felt  much  lower  than  usual,  but  I  could  discover  no  orifice. 
Dr.  Robertson  had  previously  detected  the  same  fact,  but  had  not 
then  communicated  the  circumstance  to  me,  thinking  he  might  be 
mistaken.  I  repeated  the  examination  many  times,  and  after  feel- 
ing the  spot  where  the  orifice  ought  to  have  been,  which  was  dis- 
tinguished by  a  small  dimple,  I  attempted  to  introduce  one  of  the 
smallest  silver  probes  I  could  get  made,  but  was  unsuccessful  in 
every  attempt.  It  then  occurred  to  me,  that  the  malformation 
might  be  owing  to  an  extension  of  the  mucous  membrane  over  the 
orifice,  in  which  condition  we  sometimes  see  the  urethra  of  a  new- 
born male  child.  I  determined  upon  giving  her  the  chance  of  a 
cure,  particularly  as  the  means  to  be  used  would  not  certainly 
produce  severe  pain.  Accordingly,  the  sharp  and  triangular 
extremity  of  a  silver  probe  was  introduced,  directed  by  the  fin- 
ger, carried  to  the  part  above  described,  and  a  perforation  made 
by  employing  a  rotatory  motion:  the  instrument  was  then  with- 
drawn, and  the  round  point  introduced,  which  then  readily  passed 
up- to  the  fundus  of  the  uterus.  For  several  days  she  complained 
of  slight  pain,  attended  with  some  discharge  of  mucus,  a  little 


110  SUPPRESSION    OF    THE    MENSES. 

tinged  here  and  there  with  bloody  specks,  and  I  did  not  think 
proper  to  interfere  farther  until  the  irritation  had  subsided.  In 
about  eight  days  I  began  to  attempt  a  farther  dilatation,  which 
was  persevered  in  daily,  the  size  of  the  instrument  being  in- 
creased, till,  by  the  twelfth  or  thirteenth  day,  I  was  able  to  in- 
troduce No.  6,  male  bougie,  to  the  fundus  of  the  uterus.  On  the 
following  day  there  was  the  appearance  of  so  much  irritation, 
both  local  and  constitutional,  that  I  made  no  farther  attempt.  In 
two  days  afterwards  she  menstruated,  and  has  been  regular  ever 
since,  and  suffers  neither  pain  nor  inconvenience.  Her  health 
and  strength  soon  recruited,  and  in  a  short  time  her  appearance 
became  quite  feminine.  I  saw  her  accidentally  a  few  weeks  be- 
fore this  article  was  written,  and  she  is  still  in  the  enjoyment  of 
good  health.1 

"In  the  case  of  amenorrhffia  from  imperfectly  formed  os  uteri, 
the  patient  had  at  various  times  been  afflicted  with  violent  ner- 
vous symptoms ;  pain  in  the  abdomen,  sometimes  of  a  distressing 
nature,  and  obstinate  affections  of  the  stomach  and  bowels ;  toge- 
ther with  occasional  retention  of  urine,  and  anomalous  hysterical 
complaints.  At  every  menstrual  period  she  passed  a  little  mucus, 
which  was  now  and  then  slightly  tinged,  but  had  never  the  na- 
tural appearance,  and  it  was  always  attended  with  great  pain. 
After  attaining  the  age  of  twenty-three,  when  her  health  was 
greatly  impaired,  and  after  she  had  tried  all  known  remedies^p 
vain,  she  most  reluctantly,  and  after  great  delay,  submitted  to  ex- 
amination, and  the  os  uteri  was  found  so  small  as  to  be  scarcely 
perceptible.  She  menstruated  satisfactorily  after  several  bougies 
had  been  passed  through  the  os  uteri,  but  I  never  succeeded  in 
penetrating  completely  into  the  cavity  of  the  uterus,  either  from 
an  obstruction  in  the  cervix,  or,  from  what  appears  to  me  to  be 
more  probable,  a  curvature  of  the  canal.  Nevertheless,  after  di- 
lating the  passage  as  far  as  could  be  reached,  (up  to  No.  7,  bou- 
gie,) she  menstruated  naturally,  freely,  and  without  pain,  and 
her  health  became  wonderfully  improved.  It  is  but  fair  to  men- 
tion, however,  that  this  case  was  also  complicated  with  extensive 
constriction  of  the  rectum,  which,  I  fear,  is  not  yet  completely 
removed." 


SECT.  II. — 2.  Of  the  Suppression  of  the  Menses. 

By  a  suppression  of  the  menses,  we  are  to  understand  the 
want  of  return  of  this  discharge,  at  the  accustomed  period,  after 

1  What  became  of  the  menstrual  fluid  that  had  been  previously  Secreted  ?  could 
it  have  been  absorbed  1  We  think  not.  Or  did  the  uterus  fail  to  secrete  it  in  con- 
sequence of  the  obstruction  of  the  neck ;  for  it  must  be  recollected,  the  symptoms 
of  secretion  had  continued  for  more  than  two  years. 


SUPPRESSION   OF   THE  MENSES.  Ill 

it  had  been  well  established,  when  not  interrupted  by  pregnancy, 
suckling,  or  disease. 

For,  however  well  established  the  menstrual  discharge  may 
be,  it  is  liable  to  be  interrupted  from  a  variety  of  causes,  inde- 
pendently of  pregnancy  and  suckling.  The  little  regard  which 
the  generality  of  females  pay  to  this  period,  exposes  them  too 
frequently  to  a  derangement  of  the  menses ;  nay,  some  I  have 
known  so  reckless  of  consequences,  as  designedly  to  interrupt 
them,  by  putting  their  feet  in  cold  water,  when  engaged  for  a 
party  of  pleasure. 

Frank  mentions  the  case  of  a  young  lady  who  put  her  feet  se- 
veral times  in  cold  water  during  the  flow  of  her  menses,  because 
she  expected  her  lover,  which  quickly  arrested  them ;  an  inflam- 
mation of  the  womb  followed,  and  she  was  brought,  dying,  into 
the  hospital  at  Vienna.  He  also  states,  on  the  authority  of  a  cele- 
brated surgeon  of  Helmstadt,  that  a  young  lady  was  attacked 
with  amaurosis  of  one  eye,  in  consequence  of  the  sudden  suppres- 
sion of  the  menses  from  putting  her  feet  in  cold  water — and  when 
this  discharge  was  recalled,  she  fortunately  recovered  the  sight 
of  her  eye.  And  of  one  of  his  relations,  of  fine  health  and  rare 
beauty,  who,  after  having  danced  all  night,  with  her  menses  on 
her,  left  the  ball-room  in  full  perspiration ;  she  would  not  wait  for 
her  carriage,  but  proceeded  home,  which  was  not  far  off.  She 
\pe  attacked  with  metritis,  and  died  on  the  fourth  day.  It  is  not, 
perhaps,  unworthy  of  observation,  that  amaurosis  has  followed,  in 
a  number  of  cases,  the  sudden  stoppage  of  the  menstrual  discharge. 

In  addition  to  the  case  just  related  by  Frank,  we  may  add  the 
one  by  Mr.  Brown,  in  Vol.  XXVI.  of  the  Edinb.  Med.  and  Surg. 
Journ.  p.  279.  In  this  case  the  patient  was  about  forty  years  of 
age — she  had  become  very  much  heated  by  a  long  walk  in  hot 
weather — at  the  end  of  her  walk  she  was  seized  with  her  cata- 
menia,  but  which  was  entirely  suppressed  by  a  drink  of  cold 
milk;  this  was  followed  by  h'eadach,  oppression,  hemiplegia, 
and  amaurosis  of  the  left  eye.  Mr.  B's  attention  was  directed 
to  the  restoration  of  the  menses,  in  which  he  succeeded  in  about 
six  months;  at  which  time  her  sight  was  restored.  Perhaps  the 
suppression  of  any  sanguineous  discharge  might  have  the  same 
consequences.  That  the  eyes  are  particularly  liable  to  affections 
from  such  like  causes,  is  rendered  at  least  probable,  by  the  case 
of  spectral  illusion  from  suppressed  hemorrhoi's,  related  in  Hufe- 
land's  Journal  for  September,  1824. 

"A  gentleman  of  Carlsruhe,  in  Silesia,  sixty  years  of  age,  and  of 
upright  character,  liberal,  unprejudiced,  constantly  engaged  with 
his  profession,  and  inclined  to  nothing  so  little  as  to  communingg 
with  the  kingdom  of  spirits,  had  long  enjoyed  good  health,  except 
that  he  had  occasionally  colic  on  exposing  himself  to  cold,  was 
liable  from  time  to  time  to  a  hemorrhoidal  flux,  and  had  a  cata- 


112  SUPPRESSION    OF   THE    MENStiS. 

ract  in  one  eye,  and  dimness  and  weakness  of  sight  in  the  other. 
A  short  time  before  he  was  seized  with  the  affection  about  to  be 
related,  he  received  a  visit  from  his  niece,  who  was  far  advanced 
in  pregnancy,  accompanied  by  her  husband.  Soon  afterwards 
the  family  received  an  alarm  from  a  house  taking  fire  near  their 
dwelling.  On  the  evening  of  that  day,  his  wife  remarked  that 
he  was  restless,  and  put  questions  in  a  singular  way.  About  six, 
when  the  candles  were  lighted,  he  insisted  with  his  wife,  that  his 
niece  had  entered  the  room,  taking  his  hand,  and  retired  on  his 
rising  to  meet  her ;  that  her  husband  escorted  her;  and  that  three 
other  persons  whom  he  did  not  know  were  also  in  the  room.  On 
going  up  stairs  to  supper,  the  spectral  company  went  along  with 
him,  and  after  supper  they  returned  with  him^to  the  lower  room, 
and  two  of  them  went  to  bed  with  him.  At  length,  tired  of  the 
illusion,  he  drew  the  coverlet  over  his  eyes,  and  leaving  the  spec- 
tres to  their  fate,  fell  asleep.  Next  morning  his  spiritual  friends 
did  not  make  their  appearance;  but  a  new  illusion  of  sight  took 
their  place.  He  thought  the  walls  of  his  apartment  were  all 
checkered  like  a  chess-board,  and  so  vivid  was  the  deception, 
that  it  obliterated  a  number  of  engravings  which  hung  on  the 
walls.  This  lasted  two  days,  and  after  it  disappeared,  his  vision 
returned  to  its  natural  state.  For  some  time  after,  he  complained 
of  weakness,  giddiness,  and  anxiety  in  the  chest.  His  appetite, 
however,  was  good ;  he  slept  well ;  and  the  pulse  was  natui^. 
He  had  not  had  any  hemorrhoidal  discharge  for  some  time 
before.  Gentle  laxatives ;  bathing  the  feet ;  and  afterwards  the 
tincture  of  cinchona,  restored  him  soon  to  his  usual  state  of 
health.  His  mind,  excepting  so  far  as  regarded  the  spectral 
illusions,  appears  to  have  been  quite  entire. 

Cold,  in  some  form  or  other,  may  be  considered  as  the  most 
frequent  remote  cause  of  this  suppression ;  and  it  maybe  applied 
either  in  the  interval,  just  as  they  are  making  their  appearance, 
or  after  they  have  flowed  some  time. 

When  cold  is  applied  in  the  interval,  with  sufficient  force  to 
prevent  the  recurrence  of  this  discharge,  the  first  notice  the  wo- 
man has  of  its  influence  is,  the  want  of  return  of  the  menses  at 
the  period  next  expected.  For  the  most  part,  at  first,  neither 
pain  nor  other  inconvenience  is  felt;  but  if  they  have  failed  for 
several  periods,  the  approach  of  ill  health  is  then  perceived,  and 
she  becomes  an  object  of  medical  care.  She  now  becomes  pale, 
emaciated,  and  is  much  enfeebled — a  train  of  nervous  symptoms 
may  be  superadded;  as  palpitation  of  the  heart,  difficulty  of 
breathing,  a  sense  of  suffocation,  especially  after  any  thing  has 
hurried  the  circulation — to  these  fluor  albus  maybe  abided,  which 
soon  aggravates  the  previous  unpleasant  symptoms. 

If  cold  be  applied  when  the  menses  are  about  to  appear,  or 
after  they  have  flowed  some  time,  the  symptoms  may  be  very 


SUPPRESSION    OF  THE   MENSES.  113 

much  varied :  in  such  cases,  the  patient  is  attacked  with  violent 
pain  in  the  head,  back,  or  howels ;  and  this  with  such  severity, 
sometimes,  as  to  create  great  anxiety  for  her  safety.  I  have 
known  temporary  derangement,  violent  hysteria,  and  severe  co- 
lics, result  from  this  cause.  For  the  relief  of  tjiese,  we  are 
obliged  to  have  recourse  to  blood-letting,  purging,  warm  bath, 
camphor,  opium,  asafoetida,  &c. ;  and  for  the  time  being,  are  ne- 
cessitated to  treat  the  complaints  as  if  they  were  independent  of 
such  a  cause.  For  we  can  very  rarely  re-establish  the  discharge, 
after  it  has  been  thus  interrupted ;  nor  should  it  always  be  at- 
tempted; for  sometimes  much  injury  is  done  by  neglecting  the 
consequences  of  this  stoppage,  by  directing  the  force  of  our  en- 
deavours to  a  recall  of  the  discharge.  I  admit,  that  after  bleed- 
ing and  purging  have  been  performed,  advantage  is  sometimes 
derived  from  either  the  general  or  partial  warm-bath,  or  hot 
fomentations  to  the  abdomen,  especially  if  pain  be  experienced  in 
the  region  of  the  uterus.  Should  pain  be  severe,  I  have  found 
nothing  answer  so  well  as  an  injection  composed  of  a  gill  of  thin 
starch,  a  tea-spoonful  of  laudanum,  and  thirty  grains  of  finely 
powdered  camphor.  If  it  be  complicated  with  hysteria,  the  addi- 
tion of  three  tea-spoonfuls  of  the  tincture  of  asafoetida,  instead  of 
camphor,  may  be  useful :  this  may  be  repeated  pro  re  nata.  If 
colic  supervene  upon  the  interruption  of  the  menses,  (after  bleed- 
ing, should  the  pulse  have  indicated  it,)  I  have  found  the  most  cer- 
tain relief  given  by  half-ounce  doses  of  the  elix.  proprietat.  every 
three  hours,  in  warm  sweetened  milk,  until  the  bowels  are  open. 
Having  pointed  out,  in  a  cursory  manner,  the  plan  of  treat- 
ment for  the  consequences  of  a  sudden  interruption  of  the  menses, 
I  shall  now  proceed  to  the  consideration  of  such  measures  as  will 
tend  to  invite  their  return.  In  doing  this  I  must  be  considered 
as  speaking  of  the  idiopathic  suppression  only,  and  of  the  mode 
of  treatment  proper  for  it.  I  must  here  premise,  that  I  do  not 
look  upon  every  deviation  in  regularity  as  a  legitimate  reason 
for  medical  interference ;  for  in  many  instances,  with  young  girls, 
and  especially  those  who  began  precociously  to  menstruate,  there 
will  be  a  want  of  precision  in  return,  that  must  not  be  mistaken 
for  disease ;  for,  did  we  subject  the  woman  to  medical  treatment 
for  every  aberration  of  this  kind,  we  should  be  condemning  her 
to  most  improper  discipline.  So,  also,  it  many  times  happens 
with  hale,  robust  young  women,  that  a  temporary  suspension  of 
the  menses  takes  place  from  coljl,  or  passions  or  emotions  of  the 
mind,1  but  which  after  a  certain  time  will  return  without  medi- 

'  A  lady  informed  me,  that  while  menstruating,  she  fell  down  stairs;  and  from 
that  moment  the  discharge  was  suspended;  nor  did  it  reappear  until  the  next 
period.  And  a  case  is  related  in  the  Lancet,  where  a  suppression  took  place, 
from  a  violent  fit  of  passion.  Lancet,  Vol.  i.  Case  ix.  p.  497.  See  also  Case,  p. 
126. 

8 


114  SUPPRESSION   OF   THE   MENSES. 

cal  application,  or  even  the  slightest  premonition.  My  rule1  on 
this  point  constantly  is,  never  to  interfere,  unless  there  be  some 
evidence  that  the  health  is  suffering  by  the  absence  of  this  dis- 
charge. For  it  very  often  happens,  if  we  draw  blood,  (especially 
perhaps  from  the  foot,)  to  the  amount  of  eight  or  ten  ounces,  or 
as  near  as  it  can  be  ascertained,  that  the  menses  should  flow  if 
they  were  not  obstructed,  we  very  often  succeed  in  immediately 
removing  the  obstruction. 

The  general  health  rarely,  if  ever,  suffers  before  three  or  four 
successive  periods  have  passed,  unless  this  obstruction  be  accom- 
panied by  a  bad  state  of  fluor  albus.  If  this  attend,  the  health 
may  be  earlier  affected;  and  then  require  to  be  immediately  no- 
ticed. The  remedies  for  this  condition  of  the  system  will  vary 
according  to  the  state  of  the  system;  and  I  cannot  too  earnestly 
recommend  attention  to  this  important  practical  point,  as  success 
in  the  treatment  of  these  complaints  almost  exclusively  depends 
upon  the  discrimination.  Perhaps  there  is  not,  in  the  whole  range 
of  medical  practice,  such  a  departure  from  principles  as  in  the 
treatment  of  certain  female  complaints — they  seem  to  be  pre- 
scribed for  with  determined  empiricism;  as  if  the  laws  which 
govern  disease  in  general  were  not  applicable  to  them.  The 
want  of  success,  in  many  of  the  complaints  of  females,  is  owing 
almost  altogether  to  the  determination  to  discover  specifics  for 
them ;  for  the  existing  condition  of  the  system  is  never  taken  into 
calculation,  when  a  prescription  is  made ;  hence,  the  almost  uni- 
form failure  of  certain  remedies  in  the  hands  of  some  practi- 
tioners, which  are  almost  as  uniformly  successful  in  the  hands  of 
others.  A  practitioner  acquires,  by  long  habit,  and  correct  ob- 
servation, a  control  over  certain  diseases,  that  will  not  yield  even 
to  the  same  remedies,  when  indiscriminately  used  by  others — 
this  tact  in  the  use  of  certain  medicines  is  but  the  result  of  ac- 
curate observations  on  the  various  conditions  of  the  circulating 
system ;  and  when  this  study  is  neglected,  it  is  a  moot  point 
whether  the  remedy  succeed  or  not. 

In  prescribing,  then,  for  the  disease,  or  rather  derangement, 
under  consideration,  it  were  almost  hopeless  to  employ  remedies 
without  the  strictest  attention  to  the  existing  state  of  the  circu- 
lating system;  the  remedy  which  will  relieve  in  one  case  may 
not  only  be  unavailing,  but  perhaps  injurious  in  another;  it  there- 
fore behooves  every  one  to  become  familiar  with  the  various 
states  of  the  pulse,  before  he  prescribes  his  remedies,  if  he  ex- 
pects to  succeed  by  their  employment. 

The  fear  of  debility  has  occasioned  the  death  of  thousands ; 
and  perhaps  to  the  end  of  time  it  will  have  its  victims — every  in- 
terruption of  a  natural  action,  which  may  involve  the  system  at 
large  with  nine-tenths  of  the  writers  upon  diseases,  originates  in 
debility;  hence  the  whole  class  of  diseases  we  are  considering  is 


SUPPRESSION   OF    THE   MENSES.  115 

supposed  to  either  originate  in,  or  be  perpetuated  by,  weakness: 
thus,  fluor  albus,  and  the  deranged  condition  of  the  menses,  are 
considered  as  diseases  of  weakness ;  than  which,  as  a  general  rule, 
nothing  can  be  farther  from  the  truth.  The  most  opposite  reme- 
dies will,  in  their  turn,  remove  the  same  diseases ;  and  the  person 
who  cannot  understand  the  reason  of  this  simple  fact,  will  never 
be  able  to  combat  them  with  success. 

Having  stated  some  general  notions  on  the  management  of  the 
complaints  under  consideration,  I  shall  now  proceed  to  detail  the 
practice  essential  in  each  particular  state  of  the  system.  When 
the  suppression  is  of  recent  date,  that  is,  not  more  than  of  three 
or  four  months'  standing,  I  almost  always  find  that  the  pulse,  so 
far  from  betraying  marks  of  debility,  manifests  a  tendency  to  an 
excess  of  action:  when  this  is  the  case,  we  should  commence  the 
treatment  with  such  remedies  and  regimen  as  will  reduce  the 
pulse  to  a  proper  standard,  before  we  proceed  to  the  exhibition 
of  such  medicines  as  shall  have  a  direct  tendency  to  produce  the 
menstruous  discharge ;  which  is  to  be  done  by  blood-letting,  by 
purging,  and  by  a  strict  vegetable  diet.  This  plan  is  so  effective, 
in  some  cases,  as  to  require  nothing  more  for  the  re-establish- 
ment of  health ;  and  in  others  so  indispensable,  that  success  can 
only  result  from  its  employment  as  a  preparative  step.  I  will 
illustrate  both  of  these  states  by  appropriate  cases. 

Case  First. 

Miss ,  after  having  stood  a  long  time  on  a  damp  brick  - 

paved  cellar  on  a  hot  day,  and  at  the  warm  employment  of  "pre- 
serving," found  herself  chilly,  and  her  menses  arrested;  her  mo- 
ther had  her  daughter's  feet  put  in  warm  water,  and  gave  her 
some  hot  pennyroyal  tea;  this  removed  the  chilliness,  but  did  not 
restore  the  discharge ;  she  was  occasionally  taking  remedies  with- 
out effect,  until  some  time  after  the  third  month  ;  at  this  time  she 
became  more  indisposed,  and  I  was  requested  to  visit  her — I 
found  her  labouring  under  severe  headach,  which  was  much  in- 
creased by  sitting  up,  or  motion ;  her  pulse  full,  and  a  little  quick- 
ened: her  tongue  slightly  furred,  her  appetite  impaired,  and  her 
bowels  costive.  I  directed  her  to  lose  twelve  ounces  of  blood ; 
to  be  freely  purged  by  senna;  and  to  confine  herself  to  rennet- 
whey,  barley  water,  or  thin  tapioca,  for  nourishment. 

Her  symptoms  were  much  less  severe  next  day,  but  not  en- 
tirely removed — I  ordered  another  dose  of  senna  tea,  and  the  same 
diet  to  be  continued:  on  my  next  visit  she  appeared  perfectly 
relieved;  but  I  insisted  on  her  using  a  spare  diet  for  some  time 
longer,  and  to  take  an  aloetic  pill  every  night:  this  plan  was  pur- 
sued for  several  days,  at  the  end  of  which  time  her  menses  made 
their  appearance. 


116  SUPPRESSION   OF    THE   MENSES. 


Case  Second. 

Miss ,  after  a  stoppage  of  her  menses  for  four  months,  de- 
sired my  advice;  her  health  of  late  began  to  suffer  considerably — 
she  was  pale  and  emaciated;  had  somefluor  albus;  headach;  loss 
of  appetite ;  and  was  readily  agitated  by  slight  causes ;  much  pal- 
pitation of  the  heart;  especially  on  going  up  stairs.  Her  pulse 
was  tense  and  hurried,  skin  hot,  and  tongue  considerably  furred : 
especially  in  the  morning.  I  ordered  her  to  lose  ten  ounces  of 
blood;  to  be  purged  by  senna,  and  to  be  confined  to  a  vegetable 
diet.  She  was  relieved  by  these  remedies ;  but  as  the  force  of 
her  pulse  was  not  entirely  subdued,  I  thought  it  best  to  keep  the 
bowels  loose,  and  confine  her  still  to  a  vegetable  diet.  This  plan 
'  was  strictly  persisted  in  for  about  ten  days,  which  reduced  her 
pulse  sufficiently  to  bear  the  tincture  of  cantharides,  in  doses  of 
five  and  thirty  drops,  three  times  a  day:  in  a  few  days  the  fluor 
albus  stopped;  and  in  a  few  more,  the  menses  made  their  appear- 
ance. Upon  these  two  cases,  I  shall  merely  remark,  that  had  I 
given  any  emmenagogue  medicine  in  the  commencement,  I  should 
not  have  had  the  pleasure  of  seeing  my  patient  so  quickly  re- 
stored— or,  in  other  words,  had  these  cases  been  treated  as  cases 
of  debility,  I  am  certain  the  complaint  would  have  been  aggra- 
vated ;  yet  in  the  last,  there  were  strong  marks  of  debility,  agree- 
ably to  the  common  notions  upon  this  subject. 

The  madder  may  be  given  more  safely  than  any  other  remedy 
with  which  I  am  acquainted,  without  such  particular  attention  be- 
ing paid  to  the  pulse,  as  it  excites  no  increase  of  action  in  it.  I 
am  in  the  habit  of  using  this  drug  without  previous  preparation, 
when  applied  to  near  the  period  at  which  the  menses  should  ap- 
pear; and  sometimes  succeed  most  promptly  with  it — indeed,  this 
is  the  only  time  at  which  it  seems  to  be  successful ;  for  if  it  fail 
then,  it  is  rarely  more  fortunate  afterwards.1 

When  the  madder  fails,  I  commence,  in  recent  cases,  with  the 
tincture  of  cantharides,  after  having  duly  prepared  the  system 
for  its  reception.  I  rarely  increase  the  quantity  more  than  ten 
or  fifteen  drops  beyond  the  original  dose,  as  the  moderate  doses 
of  thirty-five  or  forty  have  always  been  found  sufficient  with  me, 
when  the  medicine  would  succeed  at  all.  Should'the  cantharides 
fail,  the  volatile  tincture  of  guaiacum  is  then  ordered :  which, 
when  exhibited  in  proper  cases,  has  never  yet  failed  in  my  hands. 
I  give  it  for  this  purpose,  with  a  confidence  I  attach  to  no  other 
medicine.  This  confidence  is  the  result  of  very  many  years'  ex- 
perience of  its  efficacy.  I  have  often  succeeded  with  it,  where 
almost  all  the  other  emmenagogues  have  failed ;  nay,  I  have 

'Seep.  107. 


SUPPRESSION    OF   THE    MENSES. 

done  more ;  I  have  found  it  to  answer  completely,  after  it  was 
said  to  have  had  a  fair  trial — but  this  fair  trial  was  very  far  from 
being  so.1  As  it  is  much  more  stimulating  than  the  madder,  or 
cantharides,  I  am  more  attentive  to  have  the  system  properly 
prepared.  I,  therefore,  generally  reduce  the  pulse  lower  than 
for  the  medicines  just  named :  this  is  easily  effected  by  the  loss 
of  a  little  more  blood  than  in  the  other  cases ;  purging  more 
freely ;  and  insisting  on  a  low  diet  for  a  few  days. 

When  speaking  of  the  tact  that  is  acquired  in  the  administra- 
tion of  certain  medicines  in  certain  diseases,  I  had  particular  re- 
ference to  the  employment  of  the  tincture  of  guaiacum  as  an  em- 
menagogue.  I  have,  for  more  than  forty  years,  almost  daily  used 
this  medicine  in  suppressed  catamenia ;  and  more  especially,  in 
those  of  long  standing,  without  its  having  failed  in  any  case ^ 
proper  for  its  use2 — more  cannot  be  said  of  any  remedy. 

I  say  this  in  the  most  perfect  good  faith,  as  I  have  learned  that 
some  of  my  brother  practitioners  have  not  been  equally  success- 
ful with  it — but  I  think  I  can  readily  account  for  their  failure: 
1st,  From  their  not  placing  the  system  in  a  proper  situation  for 
its  use ;  and,  2dly,  by  not  properly  persevering  in  the  remedy. 
Neglecting  these  important  points,  it  can  readily  be  imagined, 
that  it  may  not  succeed ;  for  I  deem  an  attention  to  them  essen- 
tial to  its  success ;  more  especially  in  those  cases  where  many 
months  of  interruption  have  existed.  I  think  one  of  its  supe- 
riorities consists  in  its  certainty  in  cases  of  very  long  standing ; 
and  I  could  readily  furnish,  from  my  note  book,  a  number  of 
instances,  where  it  succeeds  to  restore  the  menses  after  an  in- 
terruption of  from  nine  months  to  nearly  three  years. 

The  mode  of  using  it  is,  a  tea-spoonful  every  morning,  noon, 
and  evening,  in  a  wine-glassful  of  sweetened  milk ;  or,  where 
not  forbidden  by  some  peculiarity  of  circumstance,  as  much  white 
wine,  as  Sherry,  Teneriffe,  or  Madeira.  The  dose  must  be  gra- 
dually increased,  in  those  cases  where  a  perseverance  beyond 
four  or  five  weeks  becomes  necessary.  Should  this  medicine 
disturb  the  bowels  too  much,  a  few  drops  of  laudanum  must  .be 

1  Mr.  Jewel  has  used  this  tincture  in  the  Middlesex  Infirmary,  and  remark^, 
"In  the  administration  of  this  medicine,  it  is  but  justice  to  state,  that  I  have  ex- 
perienced that,  which  in  common  we  experience  from  all — occasional  disappoint^* 
ment;  at  the  same  time  I  conceive  there  is  no  medicine  whose  effects  are  morjl^ 
certain,  provided  the  catamenial  suppression  does  not  exist  as  a  consequence <ff^ 
any  organic  disease." — Lond.  Med.  and  Phys.  Journ.     And  Dr.  Macleod,  the 
editor  of  this  Journal,  in  a  note  to  Dr.  Jewel's  Report,  says  that  he  has  been  in 
the  habit  of  employing  the  medicine,  "  and,  in  general,  with  very  satisfactory  re- 
sults." 

*  By  a  proper  case  I  mean,  where  the  suppression  is  idiopathic,  and  not  one 
in  which  the  uterus  has  its  functions  interrupted  by  disease,  or  pregnancy — for, 
in  the  latter,  I  have  in  two  or  three  instances  been  imposed  upon,  notwithstand-  • 
ing  all  my  caution :  and  where  I  dared  not  suppose  this  condition  to  exist.  But  by 
these  few  cases,  I  learned,  so  far  as  they  would  go,  that  it  would  not  produce 
abortion. 


118  SUPPRESSION   OF  THE   MENSES. 

added  to  each  dose ;  but  if,  on  the  contrary,  they  should  not  be 
sufficiently  opened,  the  addition  of  a  little  of  the  resin  of  jalap, 
or  of  powdered  rhubarb,  will  be  an  improvement. 

As  the  tincture  I  employ  is  different  from  the  tincture  of  the 
shops,  I  think  it  right  to  subjoin  my  formula. 

R  Pulv.  G.  Gnaiac.  opt.         giv. 
Carbon,  sod.  vel.  potas.     .^iss. 
Pulv.  Piment.  -    -    -    -  !|j. 
Alcohol,  dilut.  -     -    -    -  ftj. 

digt. — for  a  few  days. 

The  volatile  spirit  of  ammonia  is  to  be  added,  pro  re  nata,  in 
the  proportion  of  a  drachm  or  two,  to  every  four  ounces  of  tinc- 
ture ;  or  less,  or  more,  agreeably  to  the  state  of  the  system. 

M.  Guibert  highly  recommends  the  use  of  Venice  turpentine, 
in  the  amenorrhoea  of  feeble,  nervous  women  of  lymphatic  tem- 
perament. He  directs  the  following  form  for  its  exhibition  : — 

U  Terebinth,  veneta.         gij. 
Sapo.  venet.     -     -    -  £iij. 
Pulv.  Rad.  Glycyrrh.  q.  s. 
f.  mass,  div.  in  pil.  Ixxv. — Two  to  be  taken  every  four  hours. 

He  says  that  he  is  rarely  obliged  to  continue  this  medicine  be- 
yond twelve  days,  even  in  inveterate  cases.1 

Dr.  Lavagna  has  published  a  number  of  cases  treated  with  in- 
jections of  ammonia  in  solution.  They  are  highly  interesting, 
as  they  discover  a  new  resource  in  this  sometimes  highly  obsti- 
nate derangement  of  the  menstrual  action. 

He  observes,  "If  we  consider  the  different  medicinal  substances 
which  compose  the  list  of  supposed  emmenagogues,  and  the*  con- 
sequences which  generally  follow  retarded  or  suppressed  men- 
struation ;  if  we  examine  the  mode  in  which  these  substances  act 
on  the  human  body,  it  will  be  readily  perceived  that  the  animating 
influence  of  love,  and  the  physical  effects  of  a  rational  indulgence 
of«the  desires  by  which  the  species  is  reproduced,  correspond 
•with  the  practical  views  by  which  we  are  guided  in  the  treat- 
ment of  amenorrhcea."     And  he  adds,  "  There  is  hardly  a  phy- 
«  ^ician,  however  limited  his  practice,  to  whose  lot  it  has  not  fallen 
•,*to  observe  young  females,  who,  at  the  age  of  puberty,  were  dull, 
•languid,  pale,  and  labouring  under  scanty  menstruation,  suddenly 
restored  to  bloom,  animation,  and  vigour,  and  to  the  salutary 
sanguineous  evacuation,  by  an  opportunity  being  afforded  them 
of  participating  in  conjugal  duties.     Whenever  I  reflected  on  this 
* 

•  '  The  spirits  of  turpentine  has  been  found  successful,  according  to  Dr.  Elliot- 
son,  in  this  stoppage.  He  used  an  ounce  of  the  spirits  of  turpentine  in  a  pint  of 
flaxseed  tea,  or  barley  water,  as  an  enemata,  and  this  was  repeated  twice,  when 
the  meases  appeared. 


IP 
.SUPPHESSION   OF    THE   MENSES.  119 

fact,  and  considered  the  numerous  cases  by  which  it  was  estab- 
lished, I  never  doubted  that  any  stimulating  medicine  which  might 
have  the  effect  of  determining  an  increased  sanguineous  afflux  to 
the  matrix  would  succeed  in  exciting  suppressed  menstrual  eva- 
cuations. Under  this  impression,  I  determined  to  make  a  trial  of 
liquid  ammonia,  in  cases  of  amenorrhrea.  This  highly  stimu- 
lating volatile  medicine,  added  to  warm  milk,  or  any  other  fluid, 
if  injected  in  suitable  quantity  into  the  cavity  of  the  matrix,  or 
along  the  canal  of  the  vagina,  is  calculated  to  produce  a  sensation 
of  orgasm,  similar  to  that  which  is  known  to  be  most  favourable 
to  the  cure  of  suppressed  menses."  Lancet,  Vol.  I.  p.  497. 
-  We  have  thought  proper  to  introduce  to  the  reader  the  rea- 
soning of  Dr.  Lavagna ;  and  though  we  do  not  altogether  agree 
to  his  theory  for  "restoring  the  suppressed  menses,"  we  never- 
theless think,  that  the  cases  by  which  he  illustrates  his  practice 
are  no  less  important  than  convincing.  We  are  of  opinion,  that 
his  plan  should  be  tried  in  cases  where  the  ordinary  means  have 
failed :  these,  however,  we  are  disposed  to  believe  would  be  few, 
if  the  plans  we  have  suggested  were  correctly  put  in  practice, 
and  duly  persevered  in.  It  is  true,  that  the  remedies  we  have 
proposed  require  oftentimes  a  long  perseverance,  and  the  stomach 
loathes  them,  from  their  quantity  and  constant  use.  Yet  with 
these  certain  disadvantages,  we  are  of  opinion,  that  the  unmar- 
ried women  in  this  country,  would  very  reluctantly  submit  to  the 
alternative,  however  imperious  the  necessity. 

The  mode  of  using  it  is  to  throw  up  the  vagina,  by  means  of  a 
female  syringe,  ten  or  twelve  drops  of  the  aqua  ammonia  purse  in 
an  ounce  of  milk  or  water,  four  or  five  times  a  day.  It  should  be 
of  such  strength  as  to  excite  an  unpleasant  irritation  in  the  part, 
after  each  trial  of  it.  If  this  prove  rather  excessive,  the  ammo- 
nia should  be  more  diluted,  or  used  in  a  smaller  quantity.  It 
would  appear,  from  the  history  of  Dr.  L.'s  cases,  that  some  un- 
pleasant feelings  are  essential  to  the  success  of  the  remedy. 

If  there  be  no  mistake  in  the  details  of  the  cases,  the  action  of 
the  ammonia  was  very  prompt,  even  where  the  suppression  had 
assumed  a  chronic  form.1  Most  of  the  cases  required  a  perseve- 
rance of  but  a  very  few  days  in  the  injection. 

And,  as  a  last  resource  for  the  girl  under  such  circumstances, 
marriage,  from  the  time  of  Hippocrates  downwards,  has  been  re- 
commended, though  of  late  with  less  confidence  than  formerly. 
As  a  mechanical  irritant  it  may  be  occasionally  useful,  though 

1  Dr.  Hosack  (New  York  Med.  and  Phys.  Jour.)  declares,  he  treated  a  case 
successfully,  of  ten  years'  standing,  by  means  of  this  remedy,  after  many  others 
had  been  unavailingly  employed.  He  directed  a  drachm  of  the  ammonia,  and  a 
pint  of  rain  water,  to  be  thrown  up  the  vagina,  three  times  a  day.  The  cure  was 
effected  in  five  weeks.  I  am  sorry  I  cannot  confirm  the  favourable  accounts  of 
Drs.  Lavagna  and  Hosack — in  my  hands  it  has  utterly  failed. 


120  SUPPRESSION   OF    THE    MENSES. 

our  own  experience  goes  but  a  little  way  to  confirm  its  utility. 
For  we  are  of  opinion,  that  authors  have  been  led  into  error  upon 
this  point,  by  not  discriminating  between  the  sanguineous  dis- 
charge, after  a  first  coitus,  and  which  is  consequent  either  to  the 
rupture  of  the  hymen,  or  from  the  severe  distention  of  the  parts, 
and  a  genuine  menstrual  discharge — for  the  first  almost  invaria-  . 
bly  takes  place  with  virgins,  though  they  may  be  perfectly  regu- 
lar, and  may  have  menstruated  but  a  few  days  previously. 

There  is  another  remedy  proposed  by  Dr.  C.  Patterson,  namely, 
stimulating  the  external  surfaces  of  the  mammae  ;  which  we  give 
for  what  it  is  worth,  until  experience  decides  upon  its  powers. 

Catharine  Power,  aged  19  years,  applied  to  me  on  the  14th 
Sept.  1832,  She  complained  of  headach,  languor,  loss  of  appe- 
tite, and  inability  to  attend  to  her  usual  business,  that  of  a  servant. 
She  stated,  that,  about  the  middle  of  April,  the  menstrual  dis- 
charge being  then  present,  she  incautiously  exposed  herself  to  cold 
in  washing  clothes  at  a  river.  The  catamenia  then  suddenly 
ceased,  had  not  since  returned,  and  from  that  period  she  had  been 
constantly  subject  to  ill  health.  She  had  consulted  different  medi- 
cal gentlemen,  and  taken  a  great  variety  of  medicines,  with  little 
advantage. 

I  directed  that  the  clavicular  half  of  the  right  mamma  should 
be  covered  with  a  sinapism.  It  was  allowed  to  remain  on  for 
thirty  minutes ;  and  on  visiting  her  in  six  or  seven  hours  after  its 
removal,  I  found  the  whole  right  breast  considerably  swollen,  hot 
and  painful.  The  next  morning  the  enlargement  of  the  mamma 
was  very  much  increased,  the  tumefaction  having  extended  to  the 
clavicle  and  axilla  of  the  irritated  side.  There  was  no  hard  cir- 
cumscribed or  prominent  tumour,  but  a  painful  diffuse  elastic  dis- 
tention of  the  mammary  gland  and  surrounding  cellular  substance. 
On  the  evening  of  the  day  next  succeeding  the  application  of  the 
sinapism,  the  poor  girl,  with  much  joy,  reported  that  the  cata- 
menia had  appeared.  The  flux  having  continued  for  three  or  four 
days  in  moderate  quantity,  she  then  found  herself  greatly  relieved 
of  the  headach  and  other  most  distressing  symptoms ;  and  in  a 
week  her  health  was  so  far  restored  that  she  ceased  to  require 
any  farther  attendance. 

In  this  case  cold  evaporating  lotions  and  gentle  saline  aperi- 
ents were  employed  to  moderate  the  local  phlogistic  engorgement. 
She  has  continued  to  menstruate  at  her  regular  periods. 

From  the  facility  with  which  the  menstrual  flux  was  induced 
in  the  preceding  case,  it  would  seem  that  the  beneficial  effects,  in 
amenorrhoea,  lately  observed  to  arise  from  the  long  continued 
daily  application  of  one  or  two  leeches  to  the  breasts,  was  entirely 
owing  to  the  great  irritation  which  the  leech-bites  had  even- 
tually produced  in  these  organs.  The  abstraction  of  blood  by 


SUPPRESSION    OF    THE    MENSES.  121 

leeches  from  the  mammse,  has  not,  according  to  the  reports  of 
the  cases  in  which  they  were  employed,  the  least  perceptible  in- 
fluence over  the  uterine  functions,  until  pain,  heat  and  excessive 
tumefaction  of  the  breast  had  been  first  developed.1 

Phlogistic  engorgement  of  the  mammae  being,  then,  the  essen- 
tial movement,  which  in  this  instance  determined  the  flow  of  the 
catamenial  discharge,  it  must  be  obvious,  that  for  the  production 
of  the  necessary  irritation  to  effect  that  engorgement,  the  simple 
application  of  a  sinapism  would  have  been,  in  every  respect,  in- 
finitely preferable  to  the  tedious  and  troublesome  process  of  the 
daily  repetition  of  leeching.  But  it  must  not  be  supposed  that 
mammary  irritation  is  applicable  to  every  form  of  amenorrhoea. 
I  know  that  it  will  not  be  successful  in  every  case,  for  I  have 
found  it  to  fail. 

Analogous  to  suppression,  may  be  considered  the  very  sparing 
quantity  of  the  menstrual  discharge — this  may  happen,  1st,  to 
young  women  in  the  prime  of  life ;  and  2dly,  to  women  pretty 
far  advanced'towards  that  period  at  which  the  menses  are  about 
to  cease.  With  the  first,  when  the  usual  quantity  fails  to  be  dis- 
charged, it  always  excites  alarm,  and  recourse  is  almost  instantly 
had  to  the  nostrums  of  old  women,  or  perhaps  regular  application 
is  made  to  the  physician.  I  have  seen  many  of  these  cases;  and 
they  may  be  classed  under  two  heads: — 1st,  Where  this  takes 
place  from  some  accidental  irregularity  in  the  secreting  powers 
of  the  uterus  ;  and,  2dly,  Where  there  is  too  early  a  tendency  to 
cessation.  The  first  may  be  again  divided  into  two  states  ;  1st, 
When,  after  it  has  continued  some  time,  the  health  seems  to  be 
impaired  pretty  much  after  the  same  manner  as  if  a  decided  sup- 
pression were  present ;  for  it  has  very  much  the  same  accom- 
panying symptoms  ;  and  when  this  happens,  the  complaint,  for  the 
most  part,  seems  to  be  relieved  by  the  same  remedies  ;  especially 
by  the  tincture  of  cantharides.2  In  the  second  state,  it  seemed 

1  These  cases  appear  to  be  strengthened  by  a  case  recorded  by  Mr.  Jones,  and 
published  in  the  Lancet  for  May,  1835.  The  subject  of  this  case  was  a  woman, 
aged  twenty-one,  who  had  been  labouring  under  suppression  of  the  menses  for 
more  than  eighteen  months,  with  much  consequent  derangement  of  her  general 
health.  She  had  been  under  a  variety  of  treatment,  without  benefit;  and  Mr. 
Jones  dosed  her  for  several  we.eks  with  aloetic  purgatives,  mineral  tonic?,  and 
vegetable  bitters,  cantharides,  secale  cornutum,  &c.  &c.,  without  producing  the 
slightest  appearance  of  the  diminution  of  her  disease.  He  then  recommended  a 
sinapism  consisting  of  equal  parts  of  mustard  and  linseed  meal,  and  water  q.  s., 
to  be  applied  over  the  whole  of  the  right  mamma,  and  there  to  remain  as  long  as 
it  could  be  borne.  The  sinapism  was  continued  for  about  an  hour  and  a  half,  and 
on  the  evening  of  the  same  day  the  breast  was  very  painful  and  much  swollen; 
which  symptoms  increased  so  much,  on  the  third  day,  as  to  cause  much  sympto- 
matic fever.  On  the  fifth  day  the  catamenia  appeared  in  considerable  quantity, 
and  continued  for  nearly  four  days.  The  patient,  after  this,  menstruated  regular- 
ly, and  is  now  in  perfect  health. — Amer.  Jour,  of  Med.  Sciences,  for  Aug.  1835. 

*  Dr.  Lavagna  uses  the  ammoniacal  injections  in  these  cases,  with  apparent 
success. 


122  SUPPRESSION    OF    THE    MENSES. 

to  be,  in  a  number  of  the  instances  which  fell  under  my  notice, 
an  habitual  condition  of  the  uterus ;  and,  though  the  quantity  dis- 
charged was  sometimes  extremely  small,  yet  all  the  natural  or 
prolific  powers  of  the  genital  system  appeared  to  be  preserved : 
for  I  have  known  pregnancy  to  follow  in  several  cases.  I  have 
prescribed  all  the  usual  remedies  for  each  of  these  cases,  with- 
out effecting  any  change  in  the  quantity  discharged ;  yet,  after 
marriage,  some  of  these  women  became  mothers.  I  have,  there- 
fore, of  late  years,  not  interfered  with  them,  where  there  was 
no  evidence  of  ill  health.  However,  it  must  be  confessed,  though 
ill  health  may  not  attend,  some  who  are  thus  circumstanced  are 
not  fruitful ;  but  in  these,  so  far  as  I  have  seen,  it  has  been  the 
anticipation  of  a  final  cessation.  I  have  met  with  three  instances, 
where  this  evacuation  had  ceased  altogether  before  the  twenty- 
fifth  year ;  and  two  before  the  thirtieth  year :  the  health  of 
these  women  appeared  to  be  as  perfect  as  if  they  had  had  this 
discharge  in  its  most  regular  manner. 

When  scanty  menstruation  takes  place  in  women  in  the  de- 
cline of  life,  it  is  not  generally  so  regular  in  its  periods  as  in 
young  women ;  yet  as  we  have  never  witnessed  any  unpleasant 
consequences  to  arise,  we  never  thought  it  proper  to  interfere ; 
especially  in  women  after  their  five  and  thirtieth  year.  This 
condition  of  the  menses  is  more  apt  to  take  place  in  unmarried 
women,  and  in  widows,  than  in  married  women. 

In  some  instances  of  young  married  women,  I  have  had 
strong  reasons  to  believe  it  was  owing  to  a  deranged  condition  of 
the  ovaria;  for  they  were  not  only  barren,  but  had  never  disco- 
vered any  deske  for  sexual  intercourse ;  or  at  least,  were  per- 
fectly indifferent  to  it. 

It  would  seem  to  follow,  from  these  observations,  that  the  cases 
of  deficient  menstruation,  in  which  the  health  appears  to  suffer  in 
a  greater  or  less  degree,  are  those  of  the  most  easy  management ; 
but  in  the  treatment  of  them,  the  same  regard  must  be  paid  to 
the  condition  of  the  vascular  system,  as  if  an  absolute  obstruction 
existed.  I  shall  relate  a  case,  by  way  of  illustrating  the  mate- 
rial points  in  question.  Mrs. ,  aged  twenty,  during  a  period 

of  her  catamenial  flow,  suddenly  heard  of  the  death  of  her  ab- 
sent husband — the  menses  were  immediately  suspended,  and 
continued  so  for  five  months ;  during  which  time  she  suffered  much 
from  a  train  of  most  untoward  nervous  symptoms:  at  the  end 
of  five  months  there  was  a  slight  show,  which  was  repeated  at 
the  end  of  another  month,  and  so  on,  for  two  or  three  periods: 
but  her  health  did  not  improve,  as  was  fondly  hoped,  by  this 
slight  discharge,  and  I  was  now  consulted.  I  found  her, 
as  stated  above,  with  a  variety  of  nervous  symptoms ;  which 
were  easily  exacerbated  by  the  slightest  mental  distress  ;  toge- 
ther with  considerable  leucorrhoea — much  heajlach;  hot  skin 


IMMODERATE   FLOW   OF   THE   MENSES.  123 

towards  evening:  costive  bowels — she  lost  ten  ounces  of  blood  ; 
was  purged  by  aloes  and  rhubarb;  kept  upon  a  milk  and  vegeta- 
ble diet ;  took  the  tincture  of  cantharides ;  and  the  next  month 
she  had  an  ample  discharge. 


SECT.  III. — 3.   Of  the  Immoderate  Flow  of  the  Menses. 

This  complaint  is  much  more  rare  than  we  should  be  led  to 
believe,  did  we  regard  popular  opinion;  or  even  some  of  the 
writers  of  practical  systems  of  either  medicine  or  midwifery.  I 
have  seen,  comparatively,  very  few  cases  of  superabundant  men- 
ses— for  in  my  consideration  of  this  subject,  I  shall  confine  my- 
self to  what  should  be  strictly  called  an  inordinate  menstrual 
secretion.  This  complaint  has  been  very  often  confounded  with 
uterine  hemorrhage  ;*  because  the  latter  almost  always  com- 
mences with  a  genuine  menstrual  evacuation,  which  continues 
for  two  or  three  days,  and  is  then  followed  by  a  discharge  of 
pure  common  blood;  all  of  which,  by  careless  observers,  has 
been  classed  under  an  "  immoderate  flow  of  the  menses."  Should 
this  confusion  be  admitted  into  the  description  of  this  complaint, 
we  need  not  be  surprised  at  the  avowed  frequency  of  immoderate 
menses. 

There  is  an  almost  endless  variety  of  uterine  constitution,  if  I 
may  so  term  it;  consequently,  there  will  be  a  corresponding  va- 
riety in  the  performance  of  its  duties ;  hence,  one  woman  will  dis- 
charge twice  or  three  times  as  much  of  the  menstruous  fluid  as 
another,  without  suffering  from  this  apparent  excess.  For,  as  re- 
spects this  discharge,  excess  must  be  regarded  as  a  relative  term  ; 
and  it  should  only  be  considered  excessive,  when  it  has  an  inju- 
rious effect  upon  the  general  health  ;  if  it  produce  no  debility,  or 
other  disagreeable  symptoms,  we  have  no  right  to  call  this  dis- 
charge immoderate  or  excessive ;  for  it  is  only  so,  as  compared 
with  those  who  may  evacuate  less,  but  yet  be  in  no  better  health. 
I  must  therefore  repeat  that  this  discharge,  in  excess,  is  of  very 
rare  occurrence;  and  that,  so  long  as  it  does  not  impair  the 
constitution,  it  should  never  be  meddled  with;  especially  if  it  be 
not  inimical  to  impregnation. 

I  am  well  acquainted  with  a  lady,  who  has  more  than  once 
assured  me,  that  from  her  earliest  recollection  of  this  discharge 
after  it  had  commenced,  (which  was  at  her  twelfth  year,)  she 
never  enjoyed  a  longer  exemption  from  it  than  ten  days,  unless 

1  Mr.  Burns  says, "  Some  women  menstruate  more  copiously  or  more  frequent- 
ly, than  by  the  general  laws  of  the  system  they  ought  to  do.  The  discharge  is 
menstruous,  and  does  not  coagulate,  which  distinguishes  this  state  from  uterine 
hemorrhage. ''  Vol.  I.  p.  155,  James's  Ed. 


124  IMMODERATE   FLOW   OF    THE   MENSES. 

she  was  pregnant,  or  suckling;  yet,  during  the  whole  of  that 
time  she  had  never  suffered  the  slightest  indisposition,  that  could 
be  attributed  to  that  cause :  she  was,  therefore,  two-thirds  of  her 
time,  with  the  exceptions  just  mentioned,  giving  issue  to  this 
discharge.  She  also  declared  her  belief,  that,  from  what  she 
could  learn  from  others,  she  evacuated  daily  as  much  as  women 
in  general;  consequently,  she  must  have  parted  with  at  least 
three  or  four  times  as  much  as  is  commonly  lost  during  a  com- 
mon period. 

Should  this  complaint  prove  excessive,  in  our  acceptation  of 
the  terra,  namely,  where  health  suffers  from  this  cause,  it  should 
be  treated,  perhaps,  as  a  hemorrhage,  properly  so  called — I  say 
perhaps ;  because,  I  have  seen  but  one  case,  where,  from  the 
quantity  of  the  discharge,  debility,  and  other  evils  were  induced ; 
and  this  case  was  treated  as  a  common  hemorrhage. 

Miss ,  aged  seventeen,  was  seized  with  a  severe  tertian, 

which,  before  it  could  be  arrested,  required  much  depletion,  and 
left  her  for  some  time  in  a  state  of  great  weakness.  After  it  was 
thought  she  was  recovered,  her  menstrual  discharges  became  very 
abundant,  and  recurred,  as  they  were  always  wont  to  do,  every 
three  weeks.  The  quantity  discharged  was  very  great,  as  far 
as  could  be  determined  by  the  pulse  at  the  time,  and  its  appear- 
ance upon  the  cloths.  She  was  very  feeble,  and  was  confined  to 
her  bed  from  weakness,  before  I  visited  her.  I  saw  her  when 
her  menstrual  period  was  upon  her ;  she  was  greatly  reduced  in 
strength,  and  was  much  emaciated.  Her  pulse  was  frequent  and 
wealt ;  her  feet  and  hands  cold ;  she  was  extremely  pale ;  dis- 
tressed by  palpitation  of  the  heart ;  ringing  in  the  ears ;  and 
great  sickness  of  stomach. 

She  was  immediately  ordered  to  have  bottles  of  warm  water 
placed  at  her  feet;  to  take  thirty  drops  of  laudanum,  with  as 
much  of  Hoffman's  anodyne  liquor ;  two  grains  of  the  sugar  of 
lead,  with  a  third  of  a  grain  of  opium,  every  hour,  until  the  dis- 
charge should  be  moderated.  The  character  of  the  discharge  I 
was  particular  to  ascertain  ;  and  from  the  most  cautious  examina- 
tion, I  had  no  hesitation  to  believe,  (contrary  to  my  first  impres- 
sion,) that  it  was  a  genuine  menstrual  flux,  of  unusual  severity. 
By  the  plan  just  mentioned,  the  discharge  was  much  moderated 
in  the  course  of  a  few  hours  ;  but  early  the  next  morning,  I  was 
sent  for  in  great  haste,  as  the  flow  had  very  much  increased.  I 
now  ordered  twenty  grains  of  the  sugar  of  lead,  a  tea-spoonful  of 
laudanum,  and  a  gill  of  lukewarm  water,  as  an  injection — this 
quickly  arrested  the  discharge ;  which  did  not  return  from  that 
time  ;  if  we  except  a  very  moderate  stillicidium  of  three  or  four 
days'  continuance.  In  the  interval,  a  nourishing  diet  was  directed 
— quiet,  and  a  mattress  to  sleep  upon ;  also  twenty  drops  of  the 
elixir  of  vitriol,  in  strong,  sweetened  rose-leaf  tea,  four  times  a 


PAINFUL    MENSTRUATION.  125 

day  and  the  bowels  kept  open  by  small  but  repeated  doses  of  the 
sulphate  of  magnesia.  On  the  arrival  of  the  next  period,  she  was 
again  attacked  with  a  flow  as  abundant  as  on  the  former  occa- 
sion ;  the  same  remedies  were  again  successfully  employed. 
During  the  succeeding  interval,  two  grains  of  the  sacch.  sat.  every 
morning,  noon,  and  evening,  were  ordered  in  lieu  of  the  vitriol ; 
she  was  directed  to  drink  freely  of  cold  chamomile  and  orange- 
peel  tea ;  a  plaster  of  Burgundy  pitch  to  be  applied  to  the  back ; 
and  the  legs  and  feet  to  be  kept  very  warmly  clothed. 

The  next  discharge  was  considerably  more  moderate,  but  still 
too  abundant;  the  sugar  of  lead  pills  were  now  given  every  two 
hours  until  the  flow  should  cease.  The  interval  was  conducted 
as  before;  and,  after  this  time,  there  was  no  farther  necessity  of 
medicine.  Exercise,  and  sea-bathing,  very  soon  confirmed  her 
health;  nor  did  she  afterwards  suffer  any  return. 

The  plan  just  detailed  proved  successful  in  the  instance  men- 
tioned ;  but  whether  it  would  be  so  in  other  cases,  my  limited 
experience  in  "excessive  menstruation,"  will  not  permit  me  to 
declare — though  I  am  disposed  to  think  it  might;  and,  under 
similar  circumstances,  I  should  certainly  adopt  it. 


SECT.  IV. — 4.  Dysmenorrhcea,  or  Painful  Menstruation. 

This  disease  is  very  common  in  our  climate ;  and  is  one  from 
which  not  only  great  suffering  is  experienced,  but  also  very  fre- 
quently one  of  great  obstinacy.  The  woman  is  obnoxious  to  it 
during  every  part  of  the  menstruating  period  of  life. 

It  would,  perhaps,  be  very  difficult  to  assign  all  its  remote 
causes :  the  most  common  are  the  application  of  cold  during  the 
flow  of  the  menses ;  taking  cold  after  abortion ;  and,  in  several 
instances,  I  have  known  it  to  follow  the  consummation  of  mar- 
riage. This  latter  cause  is,  perhaps,  the  most  difficult  of  expla- 
nation ;  for  it  would  seem  to  have  no  such  agency,  reasoning  & 
priori.  In  a  number  of  other  instances,  the  causes  appeared  to 
be  so  hidden,  as  not  to  be  cognizable.  The  married  and  the 
single  woman  are  alike  subject  to  it. 

rlhe  suffering,  at  the  menstrual  periods,  is  sometimes  severe 
beyond  description :  it  resembles,  in  intensity,  the  pains  of  labour, 
or  of  abortion,  properly  so  called ;  for,  to  either,  the  case  may  be 
said  to  have  a  strong  analogy.  It  usually  commences  by  a  slight 
tnenstruous  discharge,  which  is  pretty  suddenly  arrested :  pain 
now  almost  instantly  ensues;  this  is  described  by  women  to  be 
of  a  forcing,  bearing  down  kind ;  returning  at  longer  or  shorter 
intervals  until  a  membranous  substance,  or  small  coagula,  are 


126  PAINFUL    MENSTRUATION. 

discharged.1  If  it  be  a  membranous  substance,  it  will  bo  found 
of  unequal  size,  sometimes  small,  at  other  times  large,  and  some- 
times it  resembles  the  cavity  from  which  it  has  been  expelled];  at 
other  times  it  will  be  broken  into  many  fragments.  After  the 
expulsion  of  this  substance,  the  woman  enjoys  ease,  unless  there 
be  a  fresh  production ;  in  which  case  it  requires,  for  its  expulsion, 
fresh  contractile  exertions  of  the  uterus. 

The  quantity  discharged  is  very  various ;  sometimes  it  is  small, 
and  at  other  times  very  abundant.  I  have  seen  a  portion  not 
much  larger  than  my  nail;  and,  again,  I  have  witnessed  as  much 
as  would  fill  a  large  tumbler.  The  periods  employed  for  the  ex- 
pulsion of  this  substance  also  vary ;  sometimes  requiring  but  a 
few  hours,  at  other  times  several  days.  The  degree  of  suffering 
is  not  always  in  proportion  to  the  quantity  of  the  substance  ex- 
pelled; indeed  the  pain  would  rather  appear  to  be  less,  when 
much  is  discharged ;  which,  perhaps,  is  not  of  difficult  explana- 
tion. 

There  appear  to  be  two  distinct  states  of  this  affection :  one, 
where  the  mammae  sympathize  with  the  uterus,  by  becoming 
tumid  and  oftentimes  extremely  painful ;  the  other  is,  where  there 
is  no  such  affection.  These  two  conditions  are  not  equally  ma- 
nageable :  the  one  accompanied  with  painful  breasts,  so  far  as  my 
observations  have  gone,  is  the  more  so  of  the  two. 

Dr.  Eberle,  in  the  paper  just  alluded  to,  confirms  the  correct- 
ness of  these  observations,  and  offers  the  following  exposition  of 
this  sympathy.  He  observes  that  I  have  offered  no  explanation ; 
but  he  thinks  it  admits  of  one,  and  says,  "I  have  observed,  for 
instance,  that  in  nearly  every  case,  where  the  breasts  become 
tumid  and  painful,  the  concreted  pseudo-membranous  substance, 
(if  any  is  cast  off,)  is  thick,  and  of  much  consistence ;  and  in  those 
where  the  mammae  do  not  sympathize,  it  is  usually  thrown  oft" 
in  the  form  of  a  thin  membrane.  In  the  former  case,  the  uterus 
is  much  more  distended,  approaching  the  condition  of  early 
pregnancy ;  and  we  may  presume  that  this  state  would  be  most 

'  It  is  to  be  lamented  that  gentlemen  who  quote  the  opinions  of  others,  should 
not  give  such  opinions  fairly.  Dr.  Eberle,  in  "offering  some  remarks  upon  the 
pathology  and  treatment  of  dysmenorrhcea,"  (Western  Journal,)  states  that  "some 
writers,  and  among  these,  Dr.  Dewees,  seem  to  think  that  this  complaint  depends 
invariably  on  the  formation  of  a  pseudo-membranous  substance  over  the  internal 
surface  of  the  uterus,  by  which  the  orifices  of  the  menstrual  exhalants  are  ob- 
structed." Now  it  is  only  necessary  to  compare  the  text  with  this  quotation,  to 
absolve  the  author,  at  least  from  such,  a  sweeping  assertion,  and  to  prove  how 
carelessly  Dr.  E.  must  have  read, — for  I  neither  say  that  the  formation  of  a  mem- 
branous substance  is  essential  to  dysmpnorrhcea,  or  intimate  that  "the  orifices  of 
the  menstrual  exhalants  are  obstructed."  I  mention  that  either  a  membranous 
substance  or  coagula  are  formed,  and  I  believe  that  this  obtains  in  all  cases  of  un- 
complicated or  idiopathic  dysmenorrhoea.  When  pain  attends  the  menstrual  pro 
cess,  without  either  of  these  products,  it  will  be  found  that  the  patient  is  labouring 
under  the  "irritable  uterus,"  and  not  dysmenorrhcea. 


PAINFUL   MENSTRUATION.  127 

apt  to  awaken  the  uterine  sympathies,  and  thus  to  excite  the 
mammary  glands."  '^4'' 

To  this  explanation  we  would  urge  the  following  objections — 
first,  that  we  have  never  observed  the  connexion  between  the 
condition  of  the  mammae,  and  thickness  or  thinness  of  the  "pseudo- 
membranous  substance;"  for  we  have  known  this  sympathy  to 
take  place  where  the  quantity  discharged  was  very  small,  and 
we  have  known  it  absent  where  this  product  was  abundant,  and 
where  even  small  cogula  were  discharged.  Secondly,  because 
Dr.  E.,  himself,  admits  the  same  thing,  virtually:  for  he  says, 
that  "  in  nearly  every  case  where  the  breasts  become  tumid,  the 
concreted  pseudo-membranous  substance,  (if  any  is  cast  off,") 
&c.  Now,  is  it  not  evident,  that  the  doubt  conveyed  by  the 
words  "  if  any  is  cast  off,"  implies  that  he  has  seen  instances  of 
mammary  sympathy,  without  this  substance,  (either  thick  or  thin,) 
being  cast  off?  And  if  this  be  so,  what  becomes  of  his  explana- 
tion, since  it  altogether  depends  upon  the  thickness  and  consist- 
ency of  the  false  membrane  ?  Thirdly,  because  we  do  not  con- 
sider the  substitution  of  one  inexplicable  phenomena  for  another 
equally  inexplicable,  as  an  explanation — for  suppose  this  mem- 
brane should  irritate  the  uterus  so  as  to  cheat  it  into  the  belief, 
that  it  was  "approaching  the  condition  of  early  pregnancy," 
has  he  informed  us,  or  does  any  body  know,  how  this  change  is 
effected  in  the  mammae,  by  every  conception  ?  We  are  all  aware 
of  the  fact  but  we  can  offer  no  "  explanation"  of  it.  Fourthly, 
assuming  Dr.  E.'s  "explanation"  to  be  correct,  does  it  inform 
us  why  such  cases  are  the  most  easily  relieved? 

Besides  the  alternate  or  labour-like  pains,  just  mentioned,  there 
is  almost  always  a  permanent  one  in  the  back,  hips,  and  loins, 
which  continues  until  the  alternate  pains  have  ceased;  indeed, 
this  aching  pain  sometimes  precedes  the  other,  and  announces 
the  discharge  to  be  at  hand. 

In  another  place,  I  have  declared,  that  the  menstruous  fluid  is 
the  product  of  a  secretory  process ; 1  I  have  there  given  my  rea- 
sons for  this  opinion ;  I  now  assume  it  as  a  principle ;  and  upon 
this  principle,  attempt  to  account  for  the  formation  of  the  mem- 
branous production,  so  often  yielded  in  dysmenorrhoea.  But  be- 
fore I  attempt  an  explanation  of  the  formation  of  this  membrane, 
I  must  again  direct  attention  to  a  very  remarkable  circumstance 
in  the  character  of  the  menstrual  blood,  namely,  its  not  possess- 
ing the  property  of  coagulation.  From  this,  it  appears  that  the 
blood,  or  a  part  of  it,  has  suffered  some  change  by  the  action  of 
the  uterine  vessels;  and  that  this  change  has  been  imposed  upon 
the  coagulating  lyinph  by  the  process  of  secretion.  I  have  as- 
signed reasons  for  this  change,  when  speaking  of  menstruation.2 

1  See  p.  94,  et  seq.  *  See  p.  93. 


128  PAINFUL   MENSTRUATION. 

Now,  it  is  not  difficult  to  suppose  that  the  uterus,  like  every  other 
organ,  may  have  its  functions  or  actions  changed  or  altered :  in 
consequence  of  which,  the  texture  of  the  coagulating  lymph, 
instead  of  being  so  subdued  as  to  prevent  coagulation,  as  it  is 
wont  to  be  when  the  uterine  secretory  action  is  perfect,  remains 
nearly  the  same  as  when  it  entered  this  viscus ;  except  that  it 
may  be  attenuated,  as  in  some  inflammatory  diseases:  and  it 
will,  from  this  imperfect  elaboration,  be  thrown  into  the  cavity 
of  the  uterus  without  being  dispossessed  of  the  power  of  separa- 
tion, and  of  coagulation. 

It  is  poured  into  the  uterus  in  a  very  gradual  manner ;  and  from 
this  circumstance,  may  tarry  there  sufficiently  long  to  separate 
into  its  constituent  parts;  for  it  now  resembles  common  blood; 
the  coloured  part,  or  red  globules,  from  their  greater  weight,  will 
leave  the  imperfectly  subdued  coagulating  lymph,  and  fall  to  the 
bottom  of  the  uterus,  and,  sooner  or  later,  be  discharged;  while 
the  coagulating  lymph,  either  in  part  or  altogether,  will  be  left  to 
spread  itself  over  the  internal  face  of  the  uterus,  and  there  quickly 
assume,  as  is  usual  with  it  when  in  contact  with  living  parts,  the 
appearance  of  a  membrane.1  This  membrane  will  be,  to  all  in- 
tents and  purposes,  an  extraneous  substance  to  the  uterus;  and 
will  sooner  or  later  urge  it  to  repeated  contractions,  to  throw  it 
off;  which  contractions  will  be  painful,  like  those  of  labour : 
hence,  the  pain  in  this  kind  of  menstruation. 

Dr.  Eberle  considers  this  explanation  as  contrary  to  sound  pa- 
thological principles,  and  to  the  import  of  the  essential  phenomena 
of  dysmenorrhoea,  and  proves  this  by  ringing  the  changes  upon 
the  word  "  Impaired."  Now,  this  word,  as  connected  with  the 
other  portions  of  the  text,  does  not  mean  "  weakened,"  but  merely 
altered,  or  changed;  and  if  this  explanation  of  its  meaning  be 
accepted, ^Dr.  E.'s  objection  to  the  pathology  offered,  is  not  per- 
haps so  irreconcilable  as  he  appears  to  think.  Besides,  we  must 
again  accuse  the  Doctor  of  reading  carelessly,  or  else  of  wresting 
the  meaning  of  our  words.  He  adds,  that  "  Analogy  also  affords 
us  good  grounds  for  this  opinion;"  (namely,  that  in  dysmenor- 
rhoea, the  uterine  system  approaches  to  a  state  of  inflammation.) 
"Lymph  is  never  thrown  out  so  as  to  form  membranous  con- 
cretions, except  from  inflamed  or  highly  irritated  surfaces." 

To  the  objections  of  Dr.  E.,  we  would  observe,  first, -that  we 
have  never  pretended  to  point  out  the  pathological  condition  of  the 
internal  surface  or  other  portions  of  the  uterus,  in  dysmenorrhoea 

*  Morgagni  explains  the  production  of  the  membranes  formed  in  the  case  he 
relates,  differently,  but  perhaps  not  more  satisfactorily.  He  says,  "It  was  easy 
to  conceive,  that  the  viscid  particles  of  the  serum  of  the  blood,  issuing  from  the 
uterine  orifices  of  the  vessels,  which  had  formerly  been  discharged  in  the  form  of 
a  fluor  albus,  were  now  become  more  viscid,  and  adhered  to  all  the  internal  parietes 
of  the  uterus,  and  by  this  means  were  concreted  into  a  polypous  membrane." 
Epist.  xlviii.  art.  12. 


;%*' 

PAINFUL    MENSTRUATION.  129 

— all  we  have  advanced  is,  that  some  change  was  effected  in  the 
secretory  surface,  and  that,  instead  of  the  fluid  discharged  during 
the  menstrual  period  presenting  the  appearances  it  is  wont  to  do 
in  the  healthy  condition  of  this  surface,  it  permits  a  separation  of 
its  constituent  parts,  thus  proving  some  change  or  imperfection 
in  the  action  which  produced  it.  Now,  whether  this  be  owing 
to  inflammation,  or  high  irritation,  we  have  neither  declared  nor 
denied.  Secondly,  we  have  in  no  part  of  this  chapter  declared, 
intimated,  nor  do  we  believe,  that  "  lymph  "  alone  is  poured  out, 
as  from  inflamed  surfaces,  in  dysmenorrhoea:  on  the  contrary, 
we  have  expressly  stated,  that  the  lymph  and  colouring  matter 
of  the  blood  were  both  present  in  the  healthy  menstruous  fluid — 
but  that  in  healthy  menstruation,  the  lymph  was  altered  by  the 
process  of  elimination,  as  it  no  longer  coagulated ;  but  not  so  in 
dysmenorrhoea.  Thirdly,  that  Dr.  E.  is  at  variance  with  him- 
self; for,  he  first  attempts  to  show,  that  the  phenomena  of  dys- 
menorrhoea, declare,  that  "  the  whole  uterine  system  is  morbidly 
increased,  and  that  it  approaches  to  the  state  of  inflammation." 
To  prove  this,  he  says  there  is  a*  "  sense  of  fulness  and  pain  in 
the  pelvis,  loins,  and  thighs — the  accelerated,  and  often  tense 
pulse — the  hot  and  feverish  skin,  decidedly  indicate  a  congested 
and  irritated  state  of  the  pelvic  organs."  We  shall  not  remark 
at  present  upon  the  fidelity  of  this  history  of  symptoms,  as  the 
assumption  of  their  truth  will  best  at  this  moment  serve  our  pur- 
pose— which  is,  to  show  what  we  have  just  asserted,  that  Dr.  E. 
is  at  variance  with  himself. 

Now  we  will  ask  any  candid  person,  at  all  conversant  with  pa- 
thology, whether  the  Doctor  has  not  made  out  clearly,  that  in 
dysmenorrhoea  there  is  both  an  inflamed  and  highly  irritated 
surface,  in  the  uterine  cavity.  Yet  he  wants  to  prove  that  there 
is  no  lymph  poured  out;  because,  "lymph  is  never  poured  out 
so  as  to  form  membranous  concretions,  except  from  inflamed  or 
highly  irritated  surfaces!" 

The  treatment  of  this  complaint  consists  in  the  temporary,  and 
the  permanent ;  the  first  consists  in  the  administration  of  remedies 
to  relieve  pain  at  the  commencement  of  and  during  the  attack  ^ 
and  the  most  efficient,  and  uniformly  certain  for  this  purpose,  that 
I  have  yet  discovered,  is  camphor  in  sufficient  doses;  the  follow- 
ing is  the  formula  I  generally  use : — 

J£.  Gum  Camphor.        J)i. 

Sp.  vin.  rect  q.  sf.  pulv. — Adde 

Pulv.  G.  Arab.        ji. 
Sacch.  alb.  q.  s. 

Aq.  Cinnam.  simp.  §i. 
M. 

One-half  of  this  draught  is  to  be  given  the  instant  pain  is  ex- 
p'erienced ;  and  if  it  be  not  relieved  in  an  hour  or  two,  the  other 
9 


130  PAINFUL  MENSTRUATION. 

half  is  to  be  given — this  quantity,  however,  is  not  always  suffi- 
cient to  subdue  pain ;  in  this  case  let  the  mixture  be  repeated — 
or  the  same  quantity  of  camphor  may  be  finely  powdered,  and 
given  in  ten  grain  doses  every  hour,  mixed  in  a  little  syrup  of  any 
kind,  until  relief  be  procured.  Sometimes  the  stomach  is  much 
deranged  in  this  complaint,  and  will  suffer  nothing  to  remain 
upon  it ;  when  this  happens,  I  order  twenty  or  thirty  grains  of 
camphor  to  be  rubbed  down  with  a  few  drops  of  the  spirit  of  wine 
to  a  very  fine  powder ;  one  drachm  of  laudanum ;  and  three 
ounces  of  thin  starch  or  flax-seed  tea,  as  an  injection  per  anum. 
The  quantity  of  this  medicine  may  be  varied  according  to  the 
exigency,  and  may  be  repeated  agreeably  to  the  necessity  of  the 
case.  Should  this  be  too  suddenly  discharged,  or  fail  in  giving 
relief,  it  may  be  repeated. 

Opium,  in  various  shapes,  has  also  been  administered;  either 
alone,  or  in  combination  with  camphor,  or  ipecacuanha.  The 
ergot  has  also  been  recommended.  I  have  tried  it;  and,  with 
one  exception,  it  has  failed.  It  must,  however,  be  declared,  that 
my  experience  in  the  use  of  this  substance  has  not  been  exten- 
sive; and  even  in  the  few  trials  I  made,  perhaps  I  may  not  have 
given  it  a  fair  chance.  These  doubts  have  lately  arisen,  from 
two  or  three  of  my  friends  telling  me  it  had  been  entirely  suc- 
cessful with  them;  and,  also,  from  a  case  of  success  occurring 
within  a  short  time  in  my  own  practice.  As  the  case  was  un- 
usual, by  combining  with  it  a  rare  occurrence,  namely,  menor- 
rhagia,  I  will  relate  it. 

In  October^  1825,  Mrs. applied  to  be  relieved  of  painful 

menstruation,  together  with  an  immoderate  discharge  of  blood. 
The  pain  appeared  to  be  produced  by  the  discharge  of  coagula ; 
at  least  there  was  no  appearance  of  membrane  in  the  fluid  she 
passed.  She  also  had  leucorrhoea  to  a  considerable  extent.  I 
ordered  her  the  ergot  in  the  following  form : — 

R.  Pulv.  secale  cornut.    gss. 
Ext.  gentian.  31. 

M.  f.  pil.  xv.      One  every  morning,  noon,  and  evening. 

She  began  the  use  of  pills  about  a  week  after  a  period,  and 
continued  them  until  the  next  made  its  appearance.  At  this 
time  she  found  herself  much  relieved,  both  as  regarded  pain,  and 
the  quantity  discharged.  The  next  period  was  still  better;  and 
since,  she  has  had  no  farther  trouble.  Warm  bath,  pediluvium, 
and  bleeding,  have  also  been  prescribed ;  but  nothing  has  suc- 
ceeded with  me  so  well  as  camphor.1 

» 

1  In  severe  cases,  or  those  which  resist  the  camphor  or  laudanum,  might  not 
the  hydrocyanic  acid  be  useful  ? 
I  am  sorry  to  say,  that  I  cannot  answer  this  query  in  the  affirmative  at  present. 


PAINFUL    MENSTRUATION.  131 

The  radical  treatment  consists  in  the  exhibition  of  remedies  in 
the  interval,  with  a  view  to  prevent  the  recurrence  of  pain — the 
one  which  has  proved  most  successful,  is  the  volatile  tincture  of 
guaiacum,  given  as  directed  in  suppressed  menses.  The  same 
regard  to  the  state  of  the  system  as  is  there  recommended,  is 
also  here  insisted  on.  Perseverance,  for  two  or  three  months, 
is  oftentimes  necessary.  I  think  I  have  observed  that  this  medi- 
cine is  more  decidedly  useful,  where  the  first  menstrual  period, 
after  its  use,  is  more  than  usually  severe.  This  has  been  pretty 
uniformly  found  a  favourable  sign. 

Though  the  tincture  of  guaiacum  has  been  generally  success- 
ful, it  has  not  been  uniformly  so.1  In  two  instances  where  it 
failed,  the  ext.  cicutte  succeeded:  and  in  one  other  where  it  had 
not  been  successful,  the  tincture  of  cantharides  gave  perfect  re- 
lief. 

I  have  never  met  with  a  case  of  fruitfulness  where  there  was 
a  discharge  of  membrane,  though  Morgagni  relates  one  in  which 
it  was  otherwise.2  As  this  is  a  rare  and  curious  case  I  shall  take 
the  liberty  of  introducing  it.  "A  noble  lady,  of  tall  stature  and 
good  health,  had  suffered  several  miscarriages  in  the  early  part 
of  her  pregnancies ;  but  between  these  miscarriages,  she  would 
carry  her  children  to  the  full  time.  She  sometimes  had  twins, 
and  very  difficult  labours.  She  was  also  troubled  slightly  with 
leucorrhoea.  Of  this  she  had  become  well  about  her  thirty-fourth 

I  have  used  this  substance  but  a  few  times,  and  then  without  the  slightest  advan- 
tage. 

The  acetate  of  ammonia  has  been  vaunted  in  this  complaint ;  but  it  has  entirely 
failed  in  the  two  or  three  trials  I  have  made  of  it,  though  given  in  much  larger 
doses  than  has  been  recommended.  I  have  lately  seen  the  muriate  of  ammonia 
much  lauded  in  the  paroxysms  of  this  complaint;  but  have  not  yet  made  trial 
of  it.  The  doses  are  from  eight  to  ten  grains,  and  taken  pro  re  nata. 

1  This  remedy  in  the  hands  of  others,  I  learn  has  not  been  equally  successful. 
I  can  only  account  for  this  in  one  of  two  ways :  first,  they  have  not,  perhaps, 
prepared  it  as  directed  ;  secondly,  and  the  most  probable,  they  have  not  persevered 
sufficiently  long  in  its  use;  for  it  is  still  successful  in  most  cases,  in  my  hands. 

"It  may  be  well  to  correct  an  error  of  quotation  in  this  place,  that  has  crept 
into  a  recent  work.  It  makes  me  say,  that  no  woman  can  conceive  who  is  la- 
bouring under  dysmenorrhoca;  now,  this  is  no  where  advanced  by  me.  Yet  I  do 
not  hesitate  to  say,  that  so  far  as  my  experience  goes,  I  have  never  met  with  an 
instance  of  fruitfulness,  where  this  membranous  product  was  expelled:  I  there- 
fore fully  agree  with  Dr.  Denman  upon  this  point.  Dr.  Mackintosh  seems  to 
have  fallen  into  a  similar  error,  when  he  thinks  Dr.  D.  wrong  upon  this  point; 
for  Dr.  D.'s  declaration  is  precisely  what  we  have  stated  above,  namely,  that  a 
woman  does  not  conceive  when  this  membrane  is  produced — but  does  not  say, 
that  no  woman  conceives  who  is  labouring  under  dysmenorrhcca ;  for  to  dysme- 
norrho-a,  this  membranous  production  is  not  a  sine  qua  non  ;  and  where  this  mem- 
brane is  not  formed,  impregnation  may  occasionally  take  place. 

I)r.  Ryan  renders  this  more  probable  than  ever;  he  relates  two  cases,  wherein 
he  says  the  dysmenorrhcea  was  aggravated  by  marriage.  These  were  instances 
of  pregnancy  occurring  during  its  existence.  But  he  observes,  that  neither  dis- 
charged this  membrane.  So  that  the  broad  assertion  remains  uncontroverted, — 
that  pregnancy  does  not  take  place,  where  this  membrane  is  discharged. 


132  PAINFUL    MENSTRUATION. 

year ;  but  was  afflicted,  at  each  return  of  her  menses,  with  pains 
resembling  labour.  About  the  second  or  third  day  she  would 
discharge  a  membranous  body  of  a  triangular  form,  and  which 
appeared  to  have  filled  up  the  whole  of  the  cavity  of  the  uterus. 

"  The  exclusion  of  this  substance  was  followed  by  a  great  lo- 
chial  discharge ;  it  did  not  always  come  away  whole ;  but  when 
this  happened,  the  lochia  also  followed.  As  the  patient  had 
abstained  for  some  time  from  intercourse  with  her  husband,  and 
had  suffered  much,  she  began  to  think  it  would  be  more  ad- 
vantageous to  her,  if  she  could  be  free  from  the  pains  for  nine 
months  at  least,  and  determined  to  lie  alone  no  longer;  where- 
fore, in  the  month  of  March,  1824,  she  became  pregnant,  but 
only  carried  the  foetus  until  June. 

"  But  in  July,  and  the  two  following  months,  her  menstrua 
flowed  properly  and  without  uneasiness.  In  October,  she  had 
no  return  of  her  menses ;  and  the  pains  returned  in  November, 
with  the  discharge  of  a  membranous  body.  She  continued  to 
suffer  from  time  to  time  after  this,  until  the  cessation  of  the 
menses  put  an  end  to  it."  Epist.  xlviii.  art.  12. 

It  is  evident  that  impregnation  took  place  in  the  instance 
above  named;  yet  the  patient  miscarried  at  the  third  month,  and 
was  not  made  to  conceive  afterwards.  It  therefore  forms  only 
an  exception  to  the  rule. 

I  have  seen  a  few  instances  of  fruitfulness  where  there  was 
painful  menstruation,  without  this  membranous  production,  but 
where  a  few  small  coagula  were  discharged.  But  such  cases  are 
rare. 

Does  this  disease  reside  in  the  ovaria,  or  in  the  secreting  sur- 
face of  the  uterus?  I  believe  it  has  its  seat  in  the  latter;  and 
that  its  being  unfavourable  to  impregnation,  is  not  owing  to  any 
influence  it  may  exert  upon  the  ovaria,  (for  I  have  reason  to 
believe  that  ova  have  been  impregnated,  but  not  finding  the 
uterus  in  a  condition  to  receive  them,  have  perished :)  but  to 
either  the  imperfect  or  the  non-formation  of  the  decidua.  I  be- 
lieve the  same  surface  furnishes  both  the  menstrual  secretion, 
and  the  efflorescence  called  the  decidua;  it  would  seem  then  to 
follow,  if  it  performed  the  first  of  these  offices  imperfectly,  it 
would  also  the  latter ;  and,  consequently,  the  ovum  would  perish 
for  want  of  a  proper  nidus. 

This  opinion  is  strengthened  by  the  facts,  that  so  soon  as  this 
wrong  action  is  changed,  the  woman  is  instantly  capable  of  being 
impregnated ;  or  in  other  words,  fecundation  becomes  success- 
ful ;  and  also  by  the  influence  of  camphor,  a  temporary  change  is 
induced  in  the  secerning  vessels  of  the  uterus,  and  the  formation 
of  membrane  is  prevented.  Were  it  necessary,  I  could  illustrate 
both  of  these  positions  by  very  many  cases ;  but,  as  it  is  the  most 


PAINFUL   MENSTBUATIOlf.  133 

remarkable  I  have  met  with,  I  shall  confine  myself  to  one  of  the 
former. 

In  1791,  I  was  applied  to  by  a  lady,  who  had  always  suffered 
at  her  menstrual  periods ;  and  who,  at  such  times,  discharged  a 
number  of  membranous  portions.  She  had  been  married  nine- 
teen years  without  being  impregnated.  After  due  preparation, 
for  she  was  very  plethoric,  I  put  her  upon  the  use  of  the  tincture 
of  guaiacum ;  in  this  she  persevered  for  three  months.  The  first 
period  after  she  commenced  the  use  of  this  medicine,  was  one  of 
prodigious  severity;  so  much  so  as  to  make  her  resolve  on  aban- 
doning it.  I,  however,  persuaded  her  to  persevere.  The  next  pe- 
riod was  better;  and  the  one  after  was  without  pain.  She  con- 
ceived immediately  after,  and  was  delivered,  in  due  time,  of  a 
fine  girl.  She  took  twenty-four  ounces  of  the  tincture.1 

As  this  disease  is  one  of  great  interest — one,  to  use  the  lan- 
guage of  Dr.  Good,  "the  frequent  returns  of  which  imbitter  the 
life  of  the  patient,  and  effectually  prohibit  all  hope  of  a  family," 
we  feel  it  a  duty  to  give  to  our  readers  the  advantage  of  every 
suggestion  for  its  relief  that  may  come  from  a  respectable  source. 
We  therefore  copy  Dr.  Mackintosh's  views  upon  this  subject  in 
his  own  language. 

"  It  always  appeared  to  me  that  there  might  be  some  mecha- 
nical cause  for  dysmenorrhoea;  but  it  was  not  till  the  year  1823, 
that  I  first  entertained  a  belief  it  might  be  owing  to  the  small  size 
of  the  og  uteri.  In  that  year  a  medical  friend  presented  me  with 
a  preparation  of  the  uterus  and  its  appendages,  in  which  the  os 
uteri  was  so  small  as  scarcely  to  admit  a  hog's  bristle ;  since  that 
period  I  have  had  many  opportunities  of  investigating  this  inte- 
resting subject,  and  have  now  obtained  many  preparations  taken 
from  the  bodies  of  individuals  who  died  of  different  diseases, 
particularly  of  phthisis,  and  whose  histories  prove  that  they  had 
laboured  under  dysmenorrhoea  from  the  very  beginning  of  their 
menstrual  lives.  In  these  preparations  of  the  uterus,  the  orifices, 
instead  of  being  shaped  like  the  mouth  of  the  tench  fish,  are 
either  circular  or  nearly  so,  and  some  of  them  are  so  small  as  only 
to  allow  a  bristle  to  pass;  others  are  a  little  larger,  admitting  a 
small  silver  probe. 

"  I  am  far  from  alleging,  however,  that  dysmenorrhoea  is  al- 
ways produced  by  a  small  os  uteri;  on  the  contrary,  I  believe  it 
may  occasionally  depend  on  inflammation  of  the  lining  mem- 
brane of  the  uterus,  as  well  as  on  inflammation  in  the  substance 
of  the  cervix  uteri,  and  on  the  encroachment  of  tumours  dimi- 
nishing the  caliber  of  the  passage  through  the  cervix.  I  only 
maintain  that  the  condition  of  the  og  uteri,  above  described,  ac- 

1  We  could  furnish  very  many  instances  of  similar  success  from  the  use  of  the 
guaiacum — indeed,  more  than  a  hundred. 


134  PAINFUL   MENSTRUATION. 

counts  satisfactorily  for  many  cases  of  dysmenorrhoea ;  so  far 
as  my  investigations  have  extended,  I  am  inclined  to  say,  it  will 
account  for  the  majority;  although  irr candour,  I  must  mention, 
that  one  preparation  in  my  possession  appears  to  invalidate  the 
evidence  afforded  by  the  others ;  in  it,  the  mouth  of  the  uterus  is 
very  small,  and  yet  the  woman  to  whom  it  belonged  had  had 
several  children;  she  died  in  a  public  establishment,  but  the  his- 
tory of  her  menstrual  life  is  unknown. 

"By  this  condition  of  the  os  uteri,  not  only  are  all  the  pheno- 
mena which  take  place  in  dysmenorrhoea  most  satisfactorily  ac- 
counted for,  but  also  the  intractable  nature  of  the  disease,  and 
the  unsatisfactory  result  of  every  mode  of  treatment  hitherto  re- 
commended. The  menstrual  discharge,  after  it  is  secreted  in  the 
uterus,  cannot  readily  escape,  in  consequence  of  the  small  size  of 
its  orifice:  distention  of  the  organ  is  the  consequence,  which,  by 
exciting  the  contraction  of  its  fibres,  produces  uneasiness  and 
pain  in  the  pelvic  region.  When  the  os  uteri  is  very  small,  and 
the  secretion  viscid,  or  mixed  with  coagulated  blood,  shreds  of 
membrane,  or  organized  masses,  then  the  distention  becomes 
more  considerable,  and  stronger  contractions  are  excited.  Some- 
times the  action  of  the  abdominal  muscles  is  called  into  play, 
and  bearing  down  or  expulsive  pains  are  produced,  resembling 
in  every  particular  the  pains  of  labour,  and  continue  till  the  ex- 
pulsion takes  place.  Mr.  Burns,  in  speaking  of  the  disease, 
states,  that  it  'sometimes  produces,  besides  uterine  pain,  spas- 
modic affection  of  the  bowels,  or  violent  bearing  down  efforts  of 
the  abdominal  muscles,  as  if  it  were  intended  to  expel  the  womb 
itself.' 

"  During  these  periodical  attacks,  inflammation  of  the  lining 
membrane  of  the  uterus,  if  it  do  not  already  exist,  is  sometimes 
excited,  and  in  the  end  the  sufferings  occasion  an  entire  break-up 
of  the  constitution.  That  dysmenorrhoea  should  be  so  intracta- 
ble, and  the  action  of  remedies  so  very  unsatisfactory  as  to  ren- 
der the  disease  an  opprobrium  to  medical  science,  are  not  to  be 
wondered  at,  if  my  views  be  hereafter  found  to  be  correct.  Be- 
fore I  had  any  opportunity  of  putting  these  opinions  to  the  test  of 
experiment,  they  also  appeared  to  me  to  be  corroborated  in  si 
very  striking  manner  by  two  circumstances : — 1.  By  the  action 
of  the  ergot  of  rye,  which  increases  the  force  of  the  uterine  con- 
tractions, quickly  expelling  the  contents  of  that  organ,  thus  short- 
ening the  patient's  sufferings  materially;  2.  By  the  admitted  fact 
which  has  been  already  mentioned,  that  women  affected  in  this 
manner  rarely,  if  ever,  conceive.  The  small  size  of  the  os  uteri 
renders  impregnation  almost  an  impossibility,  by  offering  a  me- 
chanical obstruction  to  the  passage  of  the  semen  into  the  cavity 
of  the  uterus,  where  it  is  proved  it  must  reach,  by  the  accurate 
experiments  of  that  ingenious  and  distinguished  physiologist,  Dr 


PAINFUL   MENSTRUATION. 

Blundell  of  London,  as  well  as  by  other  facts  which  it  is  unne- 
cessary to  mention  in  this  place. 

"  These  views  appear  to  me  to  be  farther  supported  by  several 
preparations  in  my  museum ;  in  one  of  which  the  cavity  of  the 
uterus  is  divided  into  two  compartments,  by  a  strong  transverse 
adhesion ;  in  a  second,  occlusion  of  the  passage  exists  at  the 
upper  part  of  the  cervix,  which  has  every  appearance  of  having 
been  produced  by  the  irritation  of  a  polypous  tumour ;  and  in  a 
third  preparation,  the  os  uteri  became  sealed  up  by  inflammatory 
action;  on  dissection,  the  uterus  was  found  enlarged,  and  con- 
tained about  two  ounces  of  puriform  matter. 

"  Treatment  of  Dysmenorrhcea. — After  the  facts  and  obser- 
vations above  mentioned  were  collected,  my  mind  became  occu- 
pied with  devising  the  best  means  likely  to  cure  the  disease.  Me- 
chanical irritation  appeared  to  be  the  only  remedy ;  but  I  hesi- 
tated for  some  years  to  carry  it  into  execution,  or  indeed,  to  pro- 
pose it,  beyond  mentioning  it  in  my  lectures,  till  the  case  of  the 
young  woman  affected  with  amenorrhoea,  [quoted  at  page  109,] 
presented  itself  in  the  year  1826.  Since  that  period  I  have  treat- 
ed fifteen  cases  of  dysmenorrhoea,  by  dilating  the  os  uteri,  and 
have  permanently  cured  all  the  patients;  among  these  the  two 
cases  of  amenorrhoea,  formerly  mentioned,  are  not  included. 

"  Of  the  fifteen  patients,  eight  were  either  young  unmarried 
women,  or  living  in  a  state  of  widowhood ;  seven  were  married, 
and  living  with  their  husbands :  of  these  seven,  four  subsequently 
fell  with  child. 

"  The  instruments  employed  to  produce  the  dilatation  are  the 
common  metallic  bougies,  of  different  sizes,  from  that  of  the  ordi- 
nary small  silver  probe  to  No.  8,  or  10.  The  operation  is  per- 
formed, (the  patient  lying  in  the  position  in  which  women  are 
usually  delivered  in  this  country,)  by  introducing  the  fore-finger 
of  the  left  hand  till  it  reaches  the  os  uteri,  for  the  purpose  of  di- 
recting the  instrument  to  the  part,  which  is  then  to  be  gently  in- 
sinuated by  a  rotatory  motion,  till  it  arrives  at  the  fundus  of  the 
uterus ;  much  force  ought  not  to  be  employed,  and  little  or  no 
pain  is  produced  by  the  operation.  The  unpleasant  consequences 
which  sometimes  take  place  in  treating  stricture  of  the  urethra 
by  similar  means,  viz.  shivering,  followed  by  fever,  occurred  in 
two  instances ;  the  fever,  however,  was  slight,  and  soon  termi- 
nated by  copious  perspiration ;  and  in  these,  some  days  were  al- 
lowed to  elapse,  before  the  instrument  was  again  used.  In  two 
of  the  cases,  the  os  uteri  was  sufficiently  large,  and  well  shaped ; 
but  the  passage  became  so  narrow  in  the  course  of  the  cervix  of 
the  uterus,  that  it  required  long-continued  efforts  before  the  small- 
est instrument  could  be  introduced ;  but  by  perseverance  the  ob- 
structions were  at  last  removed,  and  the  patient  cured.  In  one 
of  these  last  two,  menstruation  was  performed  without  pain  till 


136  PAINFUL  MENSTRUATION. 

after  marriage,  when  dysmenorrhoea  occurred.  The  other  was 
a  young  unmarried  woman,  who  menstruated  with  ease  for  seve- 
ral years,  but  after  long  exposure  to  cold  and  moisture,  the  men- 
strual discharge  became  for  a  time  suppressed,  and  ever  after 
was  performed  with  pain.  The  late  Dr.  Kellie,  of  Leith,  was 
also  consulted  about  this  case,  and  had  I  not  been  encouraged 
by  his  advice,  I  should  not  have  attempted  the  operation ;  as  on 
the  posterior  lip  of  the  os  uteri,  several  small  elevations,  like 
incipient  tubercles,  were  felt.  This  woman  called  upon  me 
eighteen  months  afterwards  in  good  health,  and  stated,  that  she 
had  not  felt  any  uneasiness,  or  experienced  any  bad  symptoms 
since  the  dilatation  was  effected. 

"  I  will  not  doubt  the  accuracy  of  these  cases,  but  only  inquire 
what  became  of  the  recrements  of  the  several  discharges  of  the 
menstrual  fluid,  which  must  have  accumulated,  one  would  think, 
after  years  of  regularity,  though  not  of  ease,  at  these  times — I 
ask,  what  had  become  of  them?  It  is  too  much  to  suppose  it 
absorbed,  though  some  countenance  is  given  to  it,  in  cases  of 
imperforate  hymen,  as  when  the  patient  has  been  operated  on, 
so  as  to  discharge  what  was  accumulated ;  the  quantity  thus  dis- 
charged has  been  much  less  than  the  aggregate  quantity  secre- 
ted at  the  regular  periods  for  years.  Suppose  a  twelvemonth 
to  have  elapsed  since  the  female  began  to  complain,  and  we  al- 
low for  each  menstrual  period,  say  four  ounces,  there  would  be 
about  50  ounces  thrown  off,  a  quantity  too  great  to  be  absorbed, 
from  one  menstrual  period  to  another. 

"A  lady,  the  subject  of  one  of  the  fifteen  cases,  was  also  per- 
fectly healthy,  and  menstruated  easily  till  the  period  of  marriage; 
but  her  health  became  impaired  soon  after,  in  consequence  of 
her  monthly  sufferings.  On  making  an  examination,  an  enlarge- 
ment was  discovered  about  half  the  size  of  a  chesnut  on  the  pos- 
terior surface  of  the  cervix  of  the  uterus.  I  undertook  the  ope- 
ration in  consequence  of  the  urgent  entreaties  of  her  friends, 
who  happened  accidentally  to  know  of  the  happy  results  which 
had  attended  it  in  other  cases,  but  I  held  out  little  hope  of  being 
able  to  do  any  good :  notwithstanding  which  a  striking  improve- 
ment in  her  health  soon  took  place;  and,  this,  in  the  end,  proved 
to  be  one  of  the  most  successful  cases,  for  menstruation  became 
easy,  the  tumour  rapidly  declined,  and  upon  making  an  exami- 
nation in  about  twelve  months  afterwards,  it  could  scarcely  be 
felt. 

"None  of  the  women  operated  upon  had  suffered  for  a  shorter 
period  than  two  years  ;  some  for  three  or  four ;  and  others  for  ten. 
Of  the  four  who  subsequently  fell  with  child,  one  had  been  mar- 
ried between  seven  and  eight  years,  and  was  reduced  to  a  shadow 
from  constant  ailments;  but  after  the  operation,  she  recovered 
her  health,  strength,  and  flesh,  and  became  pregnant  at  about 


PAINFUL    MENSTRUATION.  137 

the  termination  of  nine  months  from  the  date  at  which  the 
bougie  was  used  for  the  last  time. 

"Another  had  been  married  three  years,  and  had  suffered  con- 
siderably in  constitution,  with  severe  nervous  symptoms  every 
month,  till  at  last  she  became  entirely  obstructed ;  and  the  abdo- 
men being  enlarged,  I  was  consulted  upon  the  supposition  that 
she  was  five  months  gone  with  child.  From  some  circumstances 
which  it  is  unnecessary  to  mention,  I  entertained  a  suspicion 
that  she  had  deceived  herself;  and  upon  making  an  examination, 
when  she  supposed  herself  to  be  in  the  seventh  month,  ascer- 
tained beyond  all  doubt  that  this  was  the  case.  In  the  process 
of  time,  the  operation  was  performed,  and  the  passage  completely 
dilated;  some  months  afterwards,  impregnation  took  place,  and 
I  have  since  delivered  her  of  two  children  at  separate  births. 

"A  third  case  is  that  of  a  lady  who  had  been  married  two 
years,  and  who  had  had  painful  menstruation  from  the  first  ap- 
pearance of  the  discharge ;  she  was  in  a  miserable  state  of  health ; 
had  taken  a  great  deal  of  medicine,  but  only  with  temporary  re- 
lief. Impregnation  took  place  after  the  third  menstrual  period 
subsequent  to  the  dilatation. 

"  The  subject  of  the  fourth  case  had  also  been  affected  from 
the  first  of  her  menstrual  life,  and  laboured  under  the  impression 
that  she  was  therefore  never  to  have  a  child.  After  dilating 
the  passages  with  No.  6  bougie,  menstruation  took  place  with 
so  much  ease,  that  she  supposed  herself  quite  cured,  and  would 
not  again  submit  to  the  operation.  Several  months  afterwards, 
however,  she  felt  a  return  of  the  pain ;  the  operation  was  again 
had  recourse  to,  and  the  dilatation  carried  as  far  as  it  could  be 
effected  with  No.  10,  which  was  accomplished  two  days  before 
her  expected  period.  Menstruation  took  place  freely,  and  with- 
out the  slightest  uneasiness ;  she  subsequently  fell  with  child, 
and  was  delivered  of  a  boy." 

We  are  certainly  much  indebted  to  Dr.  M.  for  his  novel  illus- 
tration of  dysmenorrhoea,  though  we  cannot  suppose  his  patholo- 
gical views  to  be  applicable  to  all  cases  of  this  complaint.  We 
shall  therefore  take  the  liberty  to  declare,  that  his  history  of  this 
complaint  amounts  to  no  more  than  as  a  variety  of  dysmenor- 
rhcsa,  and  that  this  variety  is  most  probably  but  a  consequence 
-of  the  previous  condition  of  the  internal  cavity  of  the  uterus,  or 
of  its  neck;  namely,  the  result  of  previous  irritation  or  inflamma- 
tion; though  we  are  not  prepared  to  deny,  that  it  may  have 
existed  as  an  idiopathic  condition  of  the  neck  of  the  uterus. 

Our  reasons  for  thinking  that  this  "mechanical  cause  of  dys- 
menorrhoea" is  but  a  rare  and  secondary  cause,  are,  First,  that 
in  many  instances  the  woman  menstruates  regularly  and  health- 
fully for  a  long  time ;  but  from  exposure  to  cold ;  upon  marriage ; 
after  an  abortion,  or  sometimes  a  labour,  this  painful  condition  of 


138  DECLINE    OP    THE    MENSES. 

the  menstrual  process  takes  place — in  neither  of  which  do  we  see 
how  the  os  tincae  can  be  so  reduced  in  size,  as  to  be  only  suffi- 
cient to  transmit  a  bristle ;  unless  we  suppose  that  either  of  the 
causes  named  is  capable  of  producing  so  much  irritation  or  in- 
flammation, as  to  cause  the  disorganization  just  named;  and,  if 
this  be  admitted,  the  dysmenorrhcea  thus  produced  is  but  a  con- 
sequence of  the  previous  irritation  or  inflammation.  Secondly, 
if  his  first  reason  be  admitted,  it  must  give  us  strong  grounds  for 
belief,  that  the  degree  of  irritation  and  inflammation  capable  of 
disorganizing  the  neck  of  the  uterus,  might  also  be  sufficient  to 
induce  painful  menstruation  without  this  disorganization ;  and 
that  when  this  disorganization  has  taken  place,  it  could  only  add 
to  the  difficulties,  and  not  be  the  exclusive  cause  of  them. 
Thirdly,  that  this  last  suggestion  is  rendered  not  only  highly 
probable,  but  is  almost  demonstrated  to  be  true,  by  the  effects  of 
camphor  in  temporarily  relieving  pain ;  and  by  that  of  the  guaia- 
cum,  permanently  removing  it — for  we  cannot  suppose  that  the 
action  of  either  of  these  substances  would  remove  the  "mecha- 
nical cause  of  dysmenorrhoea."  Yet,  as  we  have  just  observed, 
we  have  seen  very  many  cases  of  dysmenorrhoea  removed  by  the 
guaiacum,  and  impregnation  follow  in  married  females. 

Nevertheless,  we  gratefully  acknowledge  the  value  of  Dr.  M.'s 
cases  and  his  mode  of  treatment;  and  we  shall  certainly  attempt 
to  follow  it  in  cases  that  are  of  unusual  obstinacy,  and  where  the 
patient  will  yield  to  the  remedy. 

We  are,  however,  far  from  thinking  that  Dr.  M.  strengthens 
his  cause  by  citing  the  action  of  ergot  upon  the  uterus,  as  a  proof 
of  the  smallness  of  the  os  uteri;  or  by  a  reference  to  the  experi- 
ments of  Blundell.  For  the  benefit  derived  from  the  use  of  the 
ergot,  (if  any  do  arise,)  is  from  its  increasing  the  power  of  the 
fundus  and  body  of  the  uterus,  to  expel  the  foreign  body  that  is 
within  it — and  which  only  proves  an  increase  of  power  in  these 
portions  of  the  uterus,  and  not  in  any  way  under  such  circum- 
stances, that  the  neck  of  the  uterus  is  narrower  than  natural. 
And,  as  regards  the  experiments  of  Blundell,  they  are  far  from 
being  confirmative  of  the  necessity  of  the  presence  of  the  semen 
in  the  cavity  of  the  uterus,  that  impregnation  may  take  place, 
except,  perhaps,  to  those  who  have  this  particular  hypothesis  to 
sustain. 


SECT.  V. — 5.   Of  the  Decline  of  the  Menses. 

The  nearer  a  woman  approaches  her  forty-fifth  year,  (cseteris 
paribus,)  will  be  the  risk  of  some  irregularity  in  the  menses :  and 
as  this  period  is  more  frequently  the  one  at  which  any  latent 
disease  of  the  uterus  shows  itself,  it  is  always  looked  forward  to 


DECLINE    OF    THE    MENSES.  139 

with  much  anxiety  by  women.  Indeed,  so  replete  is  this  time 
with  horrors  to  many,  that  we  may  very  justly  suspect  appre- 
hension to  be  the  cause  of  some  of  the  distressing  symptoms 
which  sometimes  accompany  this  interesting  process  of  the  hu- 
man uterus. 

In  delicate  women,  and  especially  those  who  have  lived  idly, 
this  period  of  life  arrives  earlier  than  those  of  a  contrary 
constitution,  and  opposite  habits.  We  have  already  noticed,  in 
our  section  on  suppression,  that  this  change  sometimes  takes 
place  at  a  very  early  period  of  life,  and  this  without  leaving  any 
injurious  consequences  behind  it:  and,  on  the  other  hand,  we 
find  many  cases  on  record,  where  this  discharge  had  continued 
with  regularity  to  a  much  longer  period  than  the  ordinary  one. 
Gardien  mentions  a  case  which  fell  under  his  own  notice,  where 
this  evacuation  continued  with  great  exactness,  until  beyond  the 
seventy-fifth  year ;  others,  still  more  uncommon,  are  mentioned 
by  various  writers.1 

The  reason  of  this  discharge  leaving  the  woman  at  this  time 
of  life,  appears  to  be  founded  in  the  highest  wisdom  and  bene- 
ficence ;  it  is  to  prevent  child-bearing  beyond  that  period  at 
which  the  mother  would  be  capable,  from  the  common  chances 
of  human  life,  of  extending  her  care  to  her  offspring,  and,  con- 
sequently, submitting  her  child  to  the  doubtful  management  of 
strangers,  or  subjecting  it  to  the  waywardness  or  caprice  of 
those  who  could  not  feel  a  parent's  affection,  nor  yield  a  mo- 
ther's devotion  to  its  necessities  at  a  time  when  its  helplessness 
would  most  require  the  kindest  offices. 

This  change  is  sometimes  effected  so  silently,  that  the  woman 
scarcely  notices  her  altered  condition ;  at  others,  its  approach  is 
BO  gradual,  as  not  to  attract  observation,  until  the  diminished 
quantity  gives  warning  that  it  is  about  to  take  its  leave  for  ever ; 
while,  again,  the  irregularity,  both  in  period  and  quantity,  may 
be  such,  as  justly  to  give  alarm,  as  well  as  to  produce  the  most 
serious  danger. 

But,  as  a  general  rule,  it  may  be  observed,  that  when  the  wo- 
man has  attained  about  her  forty-fifth  year,  she  finds  her  menses 
to  become  irregular,  both  in  the  quantity  of  fluid  evacuated,  and 
in  the  periods  they  observe ;  being  sometimes  in  advance,  and  at 
others  not  appearing  until  long  after  the  accustomed  time.  The 
woman  also  finds  some  alteration  has  taken  place  in  her  general 
health;  she  becomes  pale,  debilitated,  and  nervous;  arising,  how- 

'  I  have  had,  very  lately,  a  lady  under  my  care,  who  menstruates  with  the 
most  perfect  regularity;  though  she  had  laboured  under  a  prolapsus  of  the  uterus 
to  a  great  extent  for  several  years.  She  is  now  in  her  sixty-fifth  year.  Her  ute- 
rus is  now  effectually  supported  by  a  pessary,  which  has  much  improved  her 
general  health. 


140  DECLINE    OF    THE    MENSES. 

ever,  for  the  most  part,  from  the  too  frequent  returns  of  this 
discharge,  or  its  too  great  abundance. 

At  this  time,  also,  the  woman  sometimes  becomes  the  victim 
of  a  strange  illusion,  should  the  menses  not  have  returned  for 
several  periods ;  for  she  now  supposes  herself  to  be  pregnant,  as 
her  abdomen  enlarges,  as  do  the  mammae ;  her  appetite  becomes 
capricious,  or  she  has  strange  longings,  &c.,  the  whole  of  the 
rational  signs  of  this  condition  being  present,  even,  in  her  imagi- 
nation, to  the  motion  of  the  child.  This  delusion  is  most  com- 
mon to  women  who  marry  late  in  life,  and  who  are  very  desirous 
of  offspring ;  more,  sometimes,  we  fear,  from  an  anxiety  to  give 
a  proof  of  their  youthfulness,  than  from  a  wish  to  become  mo- 
thers, at  their  time  of  life.  But  this  youthful  hope  is  soon  to  be 
destroyed — and,  perhaps,  for  ever.  For  now  the  breasts  lose 
their  intumescency ;  the  morning  sickness  vanishes ;  the  swelling 
of  the  abdomen  subsides;  the  imagined  stirrings  of  the  foetus 
cease,  or  the  sensation  becomes  so  unequivocal  as  to  satisfy  that 
it  arises  from  the  movement  of  wind ;  and,  to  put  every  thing 
beyond  hope,  the  menses  return  in  overwhelming  quantity,  and 
thus  the  poor  woman  but  too  certainly  becomes  the  butt  of  the 
unfeeling  and  the  ridicule  of  the  unthinking.  It  is,  therefore, 
highly  proper,  that  practitioners,  and  especially  the  younger  part 
of  them,  should  be  put  upon  their  guard  in  respect  to  this  condi- 
tion of  the  patient,  and  not  too  easily  yield  credence  to  all  her 
wishes  may  dictate,  or  absolutely  to  treat  as  an  impossibility,  a 
circumstance  of  which  there  is  occasionally  an  example.1 

It  seems  that  the  apprehensions  of  this  period  of  life  have  arisen 
mainly  from  the  notions  entertained  of  the  final  cause  of  the 
menses :  namely,  that  it  gives  vent  to  peccant  humours.  But 
females  should  be  made  to  know,  that  all  this  is  purely  the  theory 
of  the  vulgar ;  as  the  menstrual  blood  is  formed  from  the  general 
mass ;  and,  consequently,  if  that  be  pure,  the  other  will  be ;  there- 
fore, the  idea  is  altogether  ill-founded.  But  unfortunately,  when- 
ever this  discharge  is  less  abundant  than  usual,  the  most  serious 
fears  are  entertained,  that  there  will  be  a  retention  of  a  portion, 
which  will  cause  disease,  either  in  the  uterus  itself,  or  in  some 
other  part  of  the  body :  hence,  a  diminished  menstruous  secretion 
is  always  more  alarming  to  the  female,  than  an  unusual  flow.  But 
it  may  be  well  to  remark,  that  there  is  a  great  difference  between 
the  cessation  of  this  discharge,  and  the  suppression  of  it.  In  the 
one  instance,  it  is  an  event  which  nature  has  designed  should 
take  place,  and  is  effected  altogether  by  arrangements  of  the  sys- 
tem itself;  and,  of  course,  one  of  its  natural  processes ;  in  a  word, 
as  much  so  as  its  commencement:  but  the  suppression,  from 

1  Women  have  conceived  at  much  later  periods,  and  given  birth  to  fine  off- 
spring. One  we  knew  at  sixty.  One  case  I  witnessed. 


DECLINE    OF   THE    MENSES.  141 

some  morbid  agency,  is  in  direct  opposition  to  the  intentions  of 
nature,  and  will,  of  course,  be  followed  by  some  baleful  conse- 
quence, if  it  continue  beyond  a  certain  period. 

The  vulgar  error,  "that  women  at  this  period  of  life  are  al- 
ways in  danger,"  is  replete  with  mischief  to  the  suffering  sex ; 
and  I  feel  it  a  duty  to  declare,  that  they  are  not  necessarily  more 
obnoxious  to  disease  at  this,  than  at  any  other  period  of  their  ex- 
istence.3 That  they  are  sometimes  liable  to  a  disease  at  this 
time,  and  that  disease  one  of  the  most  terrible  in  the  long  list  of 
human  infirmities,  I  admit;  but  must,  nevertheless,  insist,  that 
Cancer,  (the  disease  to  which  I  allude,  and  the  one  so  much 
dreaded,)  is  more  rare  in  the  uterus  than  in  certain  other  portions 
of  the  body ;  for  instance,  the  mammae ;  and,  perhaps,  I  am  within 
the  truth,  when  I  say,  that  there  are  three  instances  of  the  latter, 
for  one  of  the  former.  If  latent  dispositions  to  disease,  either  in 
the  uterus  or  other  parts,  become  active  about  this  period  of  life, 
it  is  not  because  the  declining  menses  excite  them ;  but  because 
the  disease  is  slow  in  developing  itself,  and  is,  perhaps,  kept  in 
check  for  a  long  time,  by  the  menstrual  discharge  serving  as  an 
important  evacuation ;  especially  when  the  uterus  may  be  the  seat 
of  the  complaint.  In  such  instances,  the  foundation  of  the  dis- 
ease was  laid,  perhaps,  at  a  time  when  the  menses  were  the  most 
perfect,  as  regards  period  and  quantity;  consequently,  they 
could  have  had  no  agency  in  its  production ;  but  on  the  con- 
trary, from  its  frequently  relieving  the  engorgement  of  the  ves- 
sels, served  to  keep  it  in  subjection  for  a  long  time;  not  as  a  spe- 
cific discharge,  but  as  a  mere  depletion ;  or,  in  other  words,  that 
if  an  equal  quantity  of  blood  could  have  been  by  any  other  means 
as  certainly  abstracted  from  the  uterus,  the  same  favourable  re- 
sult would  have  followed.  Coincidences  in  the  human  system 
are  so  common,  that  they  are  frequently  mistaken  for  cause  and 
effect :  hence,  the  cessation  of  the  menstrual  discharge,  and  the 
appearance  of  scirrhi  and  cancers,  are  considered  as  cause  and 
effect. 

At  this  period  of  life,  nothing  will  so  effectually  secure  the  wo- 
man against  injuries  which  may  arise  from  the  irregularities  of 
the  menstrual  discharge,  as  a  well  regulated  regimen.  By  regi- 
men, in  this  place,  we  would  wish  to  be  understood,  not  only 
eating  and  drinking,  but  exercise  of  both  body  and  mind,  in- 
cluding the  proper  government  of  the  passions;  in  a  word,  every 
thing  which  relates  to  both  moral  and  physical  existence. 

1  Indeed,  it  would  seem  that  this  period  of  female  life  is  freer  from  diseases 
causing  death,  than  almost  any  other.  By  some  late  observations  made  on  the 
bills  of  mortality  in  France,  by  M.  Boiniston  of  Chateauneuf,  it  appears  that 
fewer  women  die  between  the  ages  of  forty  and  fifty,  than  men,  or  indeed  at  any 
other  period  of  their  lives  after  puberty.  And,  farther,  that  if  this  change  is 
effected  without  much  disturbance,  that  they  live  not  only  longer  than  meji,  but 
are  freer  from  morbid  inconvenience. 


142  DECLINE    OF   THE   MENSES. 

A  well  ordered  course  of  exercise  in  the  open  air  in  well  selected 
weather,  and  great  simplicity  of  diet,  is  of  the  utmost  importance 
to  the  female  at  this  period  of  life,  and  should  never  be  neglected, 
if  it  be  possible  to  indulge  in  them.  By  these  means,  the  nervous, 
muscular,  vascular,  and  lymphatic  systems,  are  all  preserved 
more  certainly  in  equilibrium  with  each  other,  since  they  are  the 
best  calculated  to  ensure  a  reciprocation  of  their  respective  offi- 
ces; and,  consequently,  to  maintain  that  condition  of  the  system 
termed  health.  Hence,  the  justness  of  the  remark,  that  the  wo- 
men who  live  in  the  country,  and  exercise  freely  in  the  open  air ; 
who  have  fulfilled  their  duties  scrupulously  as  mothers,  by  suck- 
ling their  children  agreeably  to  the  views  of  nature ;  who  do 
not  goad  their  systems  by  over-stimulating  food  and  drinks;  who 
do  not  relax  their  bodies  by  too  long  indulgence  in  bed,  have  but 
little  suffering  at  this  period. 

From  this  it  will  follow,  that  a  milk  and  vegetable  diet,  toge- 
ther with  pure  water  as  a  drink;  regular  exercise,  not  carried  to 
fatigue ;  keeping  the  bowels  open  by  well-selected  food,  as  the 
fruits  of  the  season  in  proper  quantities ;  the  bran  bread,  if  ne- 
cessary ;  but  not  by  medicine,  unless  absolutely  required.  Go- 
verning the  temper;  restraining  the  passions,  as  well  mental  as 
animal,  will  largely  contribute  to  the  safety  and  comfort  of  this 
period.  All  that  we  have  just  recommended,  is  calculated  to 
place  the  system  in  a  condition,  by  which  it  shall  preserve  its 
various  forces;  have  its  irritability  diminished;  its  sensibility 
moderated;  and  pretty  certainly  prevent  that  condition  of  the 
blood  vessels,  most  decidedly  unfriendly  to  the  general  health  at 
this  time,  called  plethora.  And,  though  last,  not  least  in  fair 
estimation,  is  an  attention  to  cleanliness.  The  external  organs 
should  be  washed  with  lukewarm  water  at  least  twice  a  day,  and 
the  whole  body  once  a  week,  by  going  into  a  lukewarm  bath. 
In  using  the  bath,  care  should  be  taken  to  come  out  of  it  as  soon 
as  the  purposes  of  cleanliness  are  answered. 

Our  next  concern  is  with  the  derangement  of  the  discharge 
at  or  about  the  period  of  cessation ;  this  will  consist,  1st,  in  a 
diminution  of  the  proper  quantity ;  and  2dly,  in  an  excess  gf  it. 
As  regards  the  first,  I  have  already  said  enough  when  treating 
of  the  suppression  of  the  menses  ;  and,  with  respect  to  the  second, 
it  must  be  treated  according  to  the  rules  prescribed  for  the  ma- 
nagement of  hemorrhage  from  the  uterus  from  any  other  cause ; 
that  is,  first,  to  diminish  the  quantity  discharging;  secondly,  to 
prevent  an  excessive  return. 

The  first  indication  is  best  fulfilled  by  rest;  by  cool  air,  and 
drinks ;  by  cold  local  applications ;  by  the  acetate  of  lead  and 
laudanum;  and  by  the  use  of  the  tampon.1  ^re  should  imme- 

'  See  Chapters  on  Uterine  Hemorrhage,  and  Menorrhagia. 


DECLINE   OP   THE   MENSES.  143 

diately  confine  a  patient  so  circumstanced  to  a  horizontal  position ; 
and  strictly  forbid  motion  of  every  kind,  even  turning  in  bed. 
We  should  admit  cool  air  with  freedom  where  practicable ;  and 
give  neither  nourishment,  nor  drinks,  except  they  be  cooled — 
the  latter  may  even  be  iced.  Cold,  applied  to  the  abdomen,  is 
frequently  useful  in  excessive  discharges  of  this  kind;  the  best 
mode  of  applying  it  is  by  large  bladders  not  quite  filled  with 
water  in  which  there  is  ice,  if  it  be  in  summer,  or  during  hot 
weather;  cold  water  alone  will  be  sufficient,  if  it  be  winter: 
during  the  use  of  this,  care  should  be  taken  that  the  feet  and 
legs  be  kept  warm.  We  should  also  give,  by  the  mouth,  two  or 
three  grains  of  the  acetate  of  lead,  every  hour  or  two ;  guarded 
with  a  sufficient  quantity  of  opium,  or  laudanum,  or  a  scruple  of 
it  with  a  drachm  of  laudanum,  and  two  or  three  ounces  of  water, 
as  an  injection — this  is  to  be  repeated  pro  re  nata.  And,  should 
these  not  control  the  discharge  upon  fair  trial,  recourse  must  be 
had  to  the  sponge  tampon.  I  have  repeatedly  seen  the  discharge 
of  blood  at  this  period  of  life,  so  enormous  and  so  rapid,  as  to 
threaten  almost  instant  exhaustion.  When  thus  excessive  it  can 
only  be  met  successfully  by  the  most  prompt  application  of  the 
most  efficient  remedies. 

Whether  this  disease  show  itself  in  the  rapid  expenditure  of 
fluid  blood,  or  in  the  repeated  expulsion  of  large  coagula,  it  must 
be  opposed  by  the  same  remedies — these  two  conditions  present 
no  difference  of  indication,  nor  any  essential  difference  in  the 
complaint  itself:  the  former,  however,  generally  requires  more 
prompt  interference  than  the  latter,  as  more  blood  is  expended 
in  a  given  time. 

The  second  indication  must  be  fulfilled  by  blood-letting^  by 
purgatives ;  by  hemlock ;  and  by  tonics.  Notwithstanding  the 
immense  loss  of  blood,  which  sometimes  takes  place  suddenly  at 
each  period  or  return  of  this  hemorrhage,  it  does  not  prevent  the 
almost  continual  draining  off  of  this  fluid,  even  when  its  violence 
is  much  abated ;  hence,  we  sometimes  find  a  greater  or  less  dis- 
charge almost  always  present:  this  renders  the  woman  not 
only  feeble,  but  keeps  her  mind  in  a  state  of  extreme  apprehen- 
sion, from  one  period  to  another.  These  two  causes,  namely, 
the  excessive  discharge,  and  mental  anxiety,  keep  the  system  in 
a  constant  state  of  excitement;  and  if  the  pulse  be  examined,  it 
will  be  found  quick  and  corded.  We  are,  therefore,  under  the 
frequent  necessity  of  abstracting  a  few  ounces  of  blood  during 
the  interval  of  each  discharge ;  especially  towards  the  approach 
of  the  period  the  disease  has  assumed  for  its  movements, — this, 
however,  varies  in  different  individuals;  and  in  even  the  same 
individual,  if  any  error  have  been  committed  in  either  diet  or 
exercise.  But  when  all  things  are  equal,  we  find  the  period 
pretty  certainly  marked;  and  it  may  be  every  three  or  four 


144  DECLINE   OF  THE   MENSES. 

weeks;  or  sometimes  even  longer.     I  have  known  two  or  three 
violent  cases,  where  the  discharge  returned  every  two  weeks. 

To  aid  the  vessels  to  contract,  we  should  confine  the  patient  to 
a  strictly  vegetable  diet ;  or  to  a  diet  of  milk,  if  this  should  agree 
with  her :  all  kinds  of  liquor,  and  spices,  should  be  forbidden ; 
and  exercise  absolutely  prohibited.  The  patient  should  sleep 
upon  a  mattress ;  and  should  be  directed  to  repose  herself  upon 
it  or  a  sofa,  as  often  as  she  may  feel  a  little  weakened,  or  fa- 
tigued by  sitting  up.  The  feet  and  legs  should,  however,  be 
kept  warm;  and,  if  habitually  cold,  should  be  rubbed  two  or 
three  times  a  week  with  spirit  or  brandy,  in  which  a  quantity  of 
the  flour  of  mustard  is  mixed,  or  use  the  mustard  bath.  (See 
note  to  page  150.) 

The  bowels  should  be  kept  open,  by  diet,  if  possible,  as  just 
suggested,  or  by  the  exhibition  of  some  mild  purgative,  as  rhu- 
barb, sulphur,  magnesia,  or  any  of  the  neutral  salts.  Against 
the  use  of  aloes  there  is  much  clamour;  but,  I  have  some  reason 
to  believe,  without  just  cause.  I  do  not  wish  by  any  means  to 
determine  the  point  at  this  time ;  as  my  experience  in  its  use  is 
yet  too  limited  to  decide  with  certainty,  though  my  favourable 
impressions  continue  to  be  strengthened.  I  think  it  proper, 
however,  to  direct  the  attention  of  the  practitioner  to  it,  that  I 
may  be  aided  by  the  experience  of  others,  in  determining  the 
powers  of  this  medicine — but  I  will  relate  what  I  know  upon  the 
subject,  and  leave  it  to  the  farther  employment  of  this  drug, 
either  to  confirm,  or  destroy  my  present  opinion.  Eothergill 
and  Gardien  are  decidedly  opposed  to  its  use. 

A  lady,  aged  forty-two  years,  for  whom  I  had  prescribed  al- 
most all  the  known  remedies  for  the  hemorrhage  under  conside- 
ration, with  very  little  benefit,  was  told  by  some  old  woman,  that 
the  hiera  picra  was  a  certain  cure  in  her  complaint:  she  men- 
tioned this,  and  I  very  candidly  stated  my  own,  as  well  as  the 
general  prejudices  against  the  principal  ingredient  in  this  com- 
pound ;  but  at  the  same  time,  observed,  that  as  the  old  woman 
who  had  recommended  it,  cited  the  cases  of  two  or  three  ladies 
who  were  relieved  by  it,  and  who  were  known  to  her,  it  would 
be  easy  to  make  the  inquiry,  and,  if  it  were  as  she  stated,  it  would 
be  well  to  give  it  a  trial,  as  every  thing  else  had  failed — the 
medicine  was  warmly  recommended  by  these  ladies;  and  she 
proceeded  to  make  use  of  the  old  woman's  prescription ;  which 
was  half  an  ounce  of  the  hiera  picra  to  a  pint  of  gin ;  of  this  a 
wine-glassful  was  directed  at  bed-time — it  was  taken,  and  the 
lady  was  completely  intoxicated  all  night,  and  very  sick  next 
morning.  Thinking  the  effects  would  next  night  be  less  severe, 
she  again  ventured  on  it,  and  with  similar  results. 

She  was  now  determined  to  abandon  it,  unless  some  less  ob- 
jectionable mode  could  be  adopted  for  its  exhibition — I  pre- 
scribed it  for  her  in  the  manner  following : — 


DECLINE   OF  THE  MENSES.  145 

R.  Hiera  Picra      gij. 
Ol.  Caryoph.      gut.  x. 
Sapo  Venet.       gr.  xij. 
Syr.  Rhsei.          q.  s. 
M.  f.  pil.  xl. 

One  of  these  was  directed  every  morning,  noon,  and  evening, 
unless  they  should  prove  too  purgative — this  did  not  happen,  as 
the  patient  was  of  an  extremely  costive  habit.  She  soon  per- 
ceived, after  she  began  the  use  of  this  medicine,  a  diminution  of 
the  discharge ;  and  by  the  time  she  had  finished  the  pills,  pre- 
scribed above,  it  was  so  much  reduced  in  quantity,  as  to  give  no- 
farther  uneasiness.  Since  this  case,  it  is  proper  to  state,  that 
several  of  a  similar  kind  have  been  under  my  care,  with  the  same 
results  from  the  same  means. 

Several  cases,  of  less  severity,  were  entirely  relieved  after  the 
use  of  the  same  formula :  from  this  it  appears,  that  in  a  number 
of  cases  in  which  this  remedy  has  been  prescribed,  the  patients 
got  well,  but  the  precise  agency  of  the  medicine  remains  to  be 
determined  by  future  observation.  I  am,  however,  convinced 
of  the  importance  of  pretty  constant,  but  gentle  purging,  in  this 
oftentimes  tedious  complaint. 

One  of  the  most  successful  general  remedies  I  have  employed, 
is  the  extract  of  cicuta ;  beginning  with  the  minimum  dose,  and 
increasing  it  gradually,  but  at  the  same  time  as  rapidly  as  the 
system  will  well  bear.  When  decided  marks  of  its  influence,, 
such  as  vertigo,  headache,  or  sickness  of  stomach,  begin  to  show 
themselves,  the  dose  is  not  to  be  increased  until  they  go  off: 
when  this  happens,  an  increased  dose  may  be  given;  and  so  on, 
until  the  complaint  has  so  far  yielded,  as  to  render  its  farther 
exhibition  unnecessary,  or  until  we  are  convinced  that  it  will  not 
succeed  in  arresting  it.  I  have  thought  this  medicine  most  useful 
in  those  cases  where  the  discharge  was  chiefly  by  coagula.  I 
have  used  the  secale  cornutum  in  tincture,  with  great  advantage, 
in  some  instances  of  this  kind,  though  by  no  means  so  certain  as 
in  the  more  active  uterine  hemorrhages.  A  small  tea-spoonful,, 
every  four  or  five  hours,  in  sweetened  water,  has,  in  some  cases,, 
put  im  almost  immediate  stop  to  the  discharge:  in  obstinate  cases, 
it  always  deserves  a  trial. 

No  class  of  medicine  has  done  so  much  mischief  in  the  com- 
plaint I  am  now  treating  of,  as  tonics — and  this  from  a  wrong 
view  of  the  disease  in  question  ;  for  it  has  been  treated  as  one  of 
debility;  consequently,  all  the  most  powerful  tonics  have  been 
put  in  requisition  for  its  cure.  Bark,  steel,  wine,  and  all  the  bit- 
ters have  again  and  again  been  unavailingly  tried,  and  oftentimes, 
the  patient  abandoned  to  the  ravages  of  this  disease,  because  it 
could  not  be  conquered  by  tonics — the  opposite  mode  of  treat- 
ment, with  such  views,  would  necessarily  be  considered  as  death, 
to  the  patient,  and  of  course,  would  not  be  employed. 
10 


146  DECLINE    OF    THE    MENSES. 

I  well  recollect  a  case  where  three  pounds  of  bark  had  been 
taken  in  less  than  two  months,  with  a  proportionate  quantity  of 
the  elixir  of  vitriol,  to  the  manifest  increase  of  the  disease :  this 
patient  was  afterwards  entirely  cured,  by  an  extremely  low  diet, 
gentle  purging  with  neutral  salts,  quiet,  and  repeated  blood-let- 
tings. I  must,  therefore,  caution  the  young  practitioner  against 
the  use  of  tonics  in  such  cases,  though  they  may  be  attended  by 
absolute  weakness  in  the  muscular  system ;  for  the  state  of  the 
vascular  system  alone  is  to  be  attended  to ;  and  here  a  corded 
pulse  must  not  be  mistaken  for  a  weak  one,  because  it  may  hap- 
pen to  be  a  small  one.  But  how  shall  we  reconcile  the  contradic- 
tory opinions  of  the  pathology  of  this  complaint,  and  that  of  the 
suppression  of  the  menses,  with  each  other  ?  It  is  insisted  on  by 
many  that  it  is  the  debility  of  the  extreme  vessels  that  prevents 
the  formation  of  the  menses  when  they  are  suppressed;  to  over- 
come this,  tonics  and  stimulants  are  advised.  In  the  menorrhagia 
of  this  period  of  life,  the  cause  of  the  too  abundant  flow  is  debility  ; 
and  tonics  and  stimulants  are  here  recommended  to  restrain  the 
excess  of  discharge ! 

With  respect  to  the  preparations  of  iron,  I  have  perfectly  con- 
vinced myself  that  they  can  never  be  usefully  employed  during 
the  active  state  of  any  hemorrhagy:  in  my  hands  they  have 
never  failed  to  do  mischief:  I  have  not  used  them,  therefore,  for 
many  years,  in  the  cases  of  which  I  am  now  speaking.  The  use 
of  wine,  I  am  also  certain,  has  done  mischief:  it  is  port  wine 
atone,  however,  that  has  any  reputation  in  such  cases ;  and  this 
has  arisen  from  its  possessing  a  slight  astringent  property — but 
this  must  also  be  strictly  forbidden.  The  bitters  will  fall  under 
a  slighter  censure  than  the  barks ;  because  they  are  generally 
much  less  powerful :  the  same  objections,  however,  attach  to  them, 
but  in  a  minor  degree. 

Tonics  are  only  admissible  where  there  is  nothing  but  debility 
to  contend  with :  they  may  then  be  advantageously  employed,  in 
properly  regulated  doses.  The  diet  may  now  consist  of  more 
generous  living;  and  when  well  ordered,  and  properly  pursued, 
may  be  looked  upon  as  the  best  possible  tonic. 

Hitherto,  I  have  been  considering  the  severer  forms  of  this 
complaint ;  I  shall  now  say  a  few  words  upon  the  occasional  ir- 
regularity of  the  menses,  both  as  to  period  and  quantity.  The 
periods  of  return  may  be  anticipated,  or  protracted;  and  the 
quantity  may  be  very  small,  or  more  or  less  excessive ;  or  it  may 
employ  a  great  many  days  for  its  evacuation,  without  the  aggre- 
gate quantity  being  very  great.  I  have  constantly  advised  against 
any  interference  at  this  period  of  life,  for  mere  irregularity,  or  ir- 
regularity with  a  diminished  discharge;  and  for  this  plain  rea- 
son, that  no  other  inconvenience  is  experienced :  and  this  is  so 
trifling  as  not  to  merit  consideration.  But  if,  with  the  irregu- 


DECLINE   OP   THE    MENSES.  147 

larity,  the  discharge  be  too  abundant,  I  treat  it  as  directed  already 
for  hemorrhage,  and  try  to  prevent  the  recurrence,  by  bleeding 
a  little  before  the  expected  return,  a  low  diet,  and  purging  with 
the  neutral  salts :  these  means  rarely  fail  to  give  relief.  • 

When  a  great  many  days  are  employed  in  the  discharge,  or  as 
the  women  term  it,  "being  almost  constantly  unwell;"  and  where 
the  aggregate  quantity  may  not  greatly  exceed  the  common 
monthly  amount,  I  have  frequently  succeeded  by  the  tincture  of 
rhatany  in  two-drachm  doses,  three  or  four  times  a  day.  Gardien 
speaks  in  very  high  terms  of  the  "  rhatany."  He  thinks  it  merits 
more  confidence  than  the  alum,  the  sanguis  draconis,  the  kino, 
the  nutgalls,  or  catechu.  He  says  that  M.  Ruitz  used  both  the 
extract,  and  the  decoction  of  the  root  of  the  rhatany.1  The,  ex- 
tract should  be  given  in  doses  of  half-drachm  or  a  drachm.  In 
severe  cases,  it  may  be  given  to  the  amount  of  two  drachms  a 
day.2  Agreeably  to  M.  Ruitz,  the  second  or  third  dose  rarely 
fails  to  produce  the  desired  effect.  The  remedy  should  be  con- 
tinued some  time  after  the  discharge  has  ceased ;  but  the  quantity 
may  be  gradually  diminished.  To  prevent  the  nausea  which  its 
bitterness  sometimes  creates,  he  advises  the  mouth  to  be  rinsed 
with  lemonade.  Frequently  bathing  the  parts  with  cold  water ; 
abstaining  from  too  much  exercise ;  and  refraining  from  a  stimu- 
lating diet,  are  of  much  consequence  to  the  cure.  The  alum  whey 
has  often  been  useful  in  similar  cases,  and  deserves  a  trial ;  the 
sugar  of  lead,  in  small  doses  with  opium,  given  daily  for  some 
time,  has  many  times  answered  every  end.3 

In  every  form  of  the  disease  under  consideration,  I  have 
thought  that  very  decided  advantage  has  constantly  resulted 
from  injections  of  the  solution  of  the  acetate  of  lead  thrown  up 
the  vagina  several  times  a  day;4  except  during  so  profuse  a  flow 
of  blood,  as  to  render  the  use  of  the  tampon  necessary.5  It  may 

1  We  allude  here  only  to  such  cases  as  have  no  organic  lesion  to  account  for 
their  irregularity;  we  shall  notice  the  other  aberrations  in  other  places. 

*I  have,  of  late,  substituted  the  extract  for  the  tincture,  and  give  it  in  the  fol- 
lowing form: — 

R.  Ext.  Rhatan.  gij. 
Pulv.  Rhaei.  gss. 
Syr.  Rhaei.  q.  s. 
M.  f.  pil.  xl. 

Of  these,  two  are  directed  to  be  taken  every  morning,  noon,  and  evening.  It  will 
be  seen  that  I  do  not  give  it  in  any  thing  like  as  large  doses  as  M.  Ruitz,  having 
found  the  quantity  prescribed  above  to  answer ;  I,  however,  should  not  hesitate  to 
give  it  in  much  larger  quantities,  if  it  were  necessary. 

'The  prejudices  against  the  use  of  the  sugar  of  lead  appear  to  be  ill-founded  : 
we  have  given  it  very  often,  without  witnessing  any  inconvenience,  except  in 
one  instance;  in  this  case  it  had  been  too  long  continued  :  it  produced  obstinate 
vomiting, 

'  The  injections  should  be  made  of  two  drachms  of  the  sugar  of  lead,  to  about  a 
pint  and  a  half  of  water. 

•I  lately  succeeded  in  arresting  a  constant  and  long-continued  flow,  by  injec- 
tions of  warm  alum  water.  A  half  ounce  of  alum  to  a  pint  of  water,  was  used. 


148  DECLINE   OF   THE   MENSES. 

also  be  proper  to  remark,  that  the  sponge,  or  tampon,  should  not 
he  suffered  to  remain  within  the  vagina  longer  than  ten  or  twelve 
hours  at  a  time.  Wjien  taken  away,  it  should  be  carefully  washed 
with  soap-suds;  and  before  it  is  again  returned,  it  should  be 
imbued  thoroughly  with  vinegar ;  or,  if  it  can  be  procured,  with 
the  pyroligneous  acid:  on  this  account,  there  should  always  be 
two  pieces  of  sponge. 

We  have  already  adverted  to  the  fact,  that  if  there  be  any 
latent  disposition  in  the  system  to  produce  scirrhus  or  to  convert 
scirrhus  into  cancer,  that  it  most  frequently  manifests  itself  at  this 
period  of  life;  hence,  as  before  observed,  the  dread  the  woman 
has  of  the  "  disappearing  of  the  menses."  And  this  is  especially 
the  case  when  the  uterus  is  the  seat  of  the  affection.  We  have 
also  declared,  that  this  manifestation  of  disease,  at  this  time,  is 
not  the  direct  consequence  of  this  change  in  the  uterine  surface ; 
but  because  a  powerful  local  means  of  preventing  congestion  in 
that  organ  is  now  removed  by  the  menstrual  fluid  not  being 
formed  to  relieve  the  engorged  state  of  the  uterine  vessels. 

It  is  highly  probable  that  the  congestion  which  always  pre- 
cedes the  menstrual  discharge,  would  continue  to  take  place  from 
time  to  time,  though  the  menstrual  secretion  might  be  interrupted; 
and  this  congestion  not  being  relieved  as  before,  may  induce  a 
part  already  strongly  disposed  to  diseased  action,  to  take  on  in- 
flammation, and  hastily  develope  scirrhus  or  cancer.  On  this 
account,  it  is  important  that  females  should  so  regulate  their  re- 
gimen, as  to  prevent  any  thing  like  undue  excitement  in  the  arte- 
rial system :  for  this  end  it  is  necessary  to  reduce  the  quantity 
of  nourishment ;  to  adopt  a  properly  regulated  system  of  exer- 
cise, to  govern  or  control  moral  influences.  By  these  modes, 
we  are  persuaded  that  the  predisposition  to  these  dangerous  af- 
fections can  be  kept  long  in  subjection. 

And,  as  the  disposition  of  the  system  at  this  period  strongly 
inclines  to  plethora,  this  state  must  be  carefully  guarded  against, 
by  every  means  capable  of  such  an  effect.  Therefore,  besides 
the  rules  suggested  for  the  "  regimen  "  of  the  woman,  she  must 
lose  a  few  ounces  of  blood  from  time  to  time,  if  the  pulse  and 
other  symptoms  declare  this  state  to  be  present,  or  if  there  be  a 
well  marked  tendency  to  it.  The  blood  may  be  abstracted  from 
the  arm  upon  common  occasions ;  but  if  there  be  pain  in  the  re- 
gion of  the  pubes,  back,  hips,  and  rectum  ;  and  especially  if  this 
be  of  the  lancinating  kind,  accompanied  by  a  sensation  of  heat 
about  the  seat  of  the  uterus,  it  should  be  taken  by  leeches,  or 
by  cupping,  as  near  the  parts  as  it  can  well  be  drawn.  The  top 
of  the  sacrum,  just  over  the  pubes,  the  groins,  or  the  labia  puden- 
di,  are  the  best  places.1  The  bowels  must  be  gently  but  regu- 

'For  the  last  two  years,  we  have  directed  the  leeches  to  be  applied  to  the  in- 
side of  the  thigh,  about  its  centre ;  so  also,  for  the  cupping.  It  is  very  much  less 


DECLINE    OF    THE     MENSES.  149 

m* 

larly  purged  by  neutral  salts,  and  the  woman  should  be  confined 
to  a  very  strict  diet;  she  must  also  avoid  all  kinds  of  exertion 
during  this  commenced  state  of  excitement. 

The  patient  should  be  attentive  at  the  same  time  to  cleanli- 
ness, as  before  directed ;  especially,  as  will  most  probably  be  the 
case,  if  these  symptoms  be  attended  by  leucorrhcea.  If  these 
measures  be  rigorously  adopted,  and  steadily  persevered  in,  there 
is  much  reason  to  believe,  that  this  congestive  condition  of  the 
uterus  will  be  much  relieved;  and,  of  course,  the  evils  arising 
from  it  diminished,  if  not  altogether  subdued. 

A  variety  of  other  affections  show  themselves  at  the  period  we 
are  now  considering;  such  as  eruptions,  erysipelatous  inflamma- 
tions, rheumatic  pains,  swelling  of  the  lower  limbs,  violent  head- 
ache, and  a  great  variety  of  nervous  or  hysterical  symptoms. 
None  of  these  require  any  peculiarity  of  treatment,  except  that 
the  loss  of  the  menses,  and  the  tendency  to  plethora,  must  al- 
ways be  kept  in  view. 

It  must,  however,  be  remarked,  that  though  hysterical  symp- 
toms are  wont  to  disappear  about  this  time,  and  to  be  sometimes 
even  violent,  owing  to  an  augmented  sensibility  of  the  nervous 
system,  yet  this  complaint  almost  always  disappears  so  soon  as 
the  system  becomes  accustomed  to  the  change  in  the  nature  of 
the  circulation,  and  its  more  general  determinations  over  the  other 
parts  of  the  system. 

It  is  highly  important,  that  the  cutaneous  circulation  and  sen- 
sibility be  properly  preserved:  for  this  reason,  the  woman  should 
avoid  all  causes  which  may  tend  to  impair  them ;  such  as  cold, 
damp  places;  too  humid  an  atmosphere;  too  thin,  or  wet,  or 
damp  clothing,  or  partial  draughts  of  air.  To  maintain  an 
equality  of  excitement  in  the  circulation,  she  should  wear  flannel 
next  her  skin,  and  carefully  protect  her  feet  and  legs  by  shoes 
of  a  proper  thickness,  and  stockings  of  a  proper  quality.  Should 
she  be  habitually  subject  to  cold  feet,  she  should  employ  the 
mustard  bath  at  least  twice  a  week,  so  long  as  this  symptom 
continues.1 

inconvenient,  and  is  certainly,  to  say  the  least,  as  efficacious.  I  think  we  have 
paid  too  little  attention,  in  this  country,  to  the  practice  of  the  French  physicians 
upon  such  occasions:  they  almost  always  apply  leeches  at  a  distance  from  the  af- 
fected part,  upon  a  well-founded  belief,  I  am  inclined  to  think,  that  a  revulsive 
effect  is  thus  produced. 

1  The  mustard  bath  is  made  by  putting  two  or  three  table-spoonfuls  of  the  flour 
of  mustard,  to  a  gallon  of  warm  water.  The  feet  are  to  be  put  in  this  just  before 
getting  into  bed  for  the  night,  and  rubbed  until  they  glow. 


150  MENORRHAGIA. 

JH  -  ^A» 

^    |r    .    •         :;;^;ro^Sfc 

y 

CHAPTER  VII. 

OF    MENORRHAGIA. 

BY  this  term  we  would  understand  an  immoderate  discharge 
of  fluid  Wood,  properly  so  called,  or  coagula,  or  both,  from  the 
internal  cavity  of  the  uterus;  recurring  at  the  menstrual  period, 
and  following  the  secretion  termed  the  menses. 

I  have  already  said  that  this  discharge  consists  of  blood,  pro- 
perly so  called,  in  contradistinction  to  the  fluid  yielded  by  the 
internal  uterine  surface  every  lunar  month,  called  the  menses. 
"When  treating  of  the  catamenia  generally,  the  difference  between 
the  menstruous  fluid  and  the  circulating  blood,  was  insisted  on ; 
and  it  is  important  that  this  distinction  be  preserved,  that  two 
different  conditions  of  the  uterus  may  not  be  confounded.1 

It  will  probably  ever  remain  a  matter  of  doubt,  whether  the 
blood  which  is  expended  in  menorrhagia  be  from  the  same  ves- 
sels as  furnish  the  menstrual  fluid,  or  from  a  distinct  set,  which 
may  terminate  upon  the  internal  uterine  surface ;  nor  is  it,  per- 
haps, at  this  moment,  of  very  great  consequence  to  determine, 
since  it  would  not  lead,  with  our  present  knowledge,  to  any  prac- 
tical good.  Reasoning,  perhaps,  would  be  against  this  identity ; 
and  would  tempt  us  to  believe,  that  the  blood  of  hemorrhagy  does 
not  proceed  from  the  same  vessels  which  furnish  the  menstrual 
fluid;  for  menorrhagia  is  always,  so  far  as  we  have  witnessed, 
preceded  by  the  regular  menstrual  discharge;2  which  it  would 
be  but  rational  to  suppose,  would  effectually  relieve  any  engorge- 
ment that  might  be  supposed  present  at  this  time;  provided  this 
accumulation  were  confined  to  the  vessels  concerned  in  the  pro- 
duction of  the  menstrual  fluid. 

1  Gardien  evidently  confounds  these  two  conditions,  both  by  the  caption  of  his 
chapter  on  this  subject,  (de  la  menorrhagia  ou  flux  immodere  des  rfglts,)  and  by 
his  text. 

1  Under  the  head  of  menorrhagia,  we  do  not  include  those  hemorrhagies  which 
arise  from  a  lesion  of  the  internal  surface  of  the  uterus,  or  a  portion  of  its  proper 
substance,  as  in  open  cancer,  or  other  ulcerations  of  this  organ.  We  confine  our- 
selves to  that  discharge  of  blood  which  follows  or  accompanies  the  menstrual  ac- 
tion. We  pretend  not  to  account  for  this  condition  of  the  uterus;  we  only  know 
the  fact  that  it  takes  place,  and  that  the  woman  may  be  liable  to  it  so  long  as 
the  menstrual  periods  continue,  be  these  longer  or  shorter.  Women  are,  there- 
fore, obnoxious  to  this  state  of  hemorrhagy  during  a  great  part  of  their  lives, 
that  is,  during  the  whole  menstrual  period;  for  we  have  no  evidence  that  this 
takes  place  after  the  congestion  of  the  uterus,  (so  necessary  for  the  menstrual 
secretion,)  ceases  to  take  place ;  though  hemorrhagies  from  lesion,  and  some  other 
causes,  do  very  often  happen  after  this  time. 


MENORRHAGIA.  151 

Besides,  did  this  flow  of  blood  proceed  from  the  same  vessels 
as  the  menstruous  fluid,  we  should  be  at  a  loss  to  understand 
how  a  hemorrhage  should  take  place  from  vessels,  after  disten- 
tion  was  diminished  by  the  evacuation  of  a  portion  of  their  con- 
tents ;  which  must  be  the  case,  did  the  vessels  which  ordinarily 
furnish  the  menstrual  blood,  also  yield  that  of  menorrhagia. 
But,  if  we  suppose  that  a  distinct  set  of  vessels  is  concerned,  we 
can  more  readily  understand  how  they  might  be  forced,  or  in- 
duced, from  any  given  local  cause,  to  open  themselves,  so  as  to 
pour  out  blood ;  since  their  distended  condition  may  not  be  re- 
lieved by  the  catamenial  discharge;  for  it  is  not  difficult  to  con- 
ceive, that  the  whole  uterus  may  be  in  a  congestive  state  at  this 
time. 

Gardien  (Traite  complete  d'Accouchemens,  vol.  i.  p.  289,) 
declares,  that  "so  great  a  relation  exists  between  menorrhagia 
and  the  menstrual  flux,  that  it  would  be  difficult  to  determine 
where  the  one  ends  and  the  other  begins."  Again :  "  In  fact,  all 
spontaneous  hemorrhages  have  the  strongest  analogy  with  the 
menstrual  flux.  The  phenomena  which  accompany  the  issue  of 
blood  are  absolutely  the  same  in  both  cases;  only,  in  menorrha- 
gia, the  flow  partly  belongs  to  an  original  law,  while  that  of  he- 
morrhages is  accidental,"  p.  289. 

It  is  evident  from  these  passages,  that  he  looked  upon  both 
discharges  to  be  the  common  blood  of  the  system ;  yet  it  is  no- 
torious they  differ  widely  in  many  particulars.  The  one  is  the 
result  of  a  secretory  process ;  the  other  is  blood  which  has 
escaped  from  confinement,  by  the  rupture  or  the  opening  of  the 
vessels  which  contained  it.  Now,  were  it  true  that  the  men- 
strual fluid  and  the  blood  thrown  off  in  menorrhagia  were  the 
same,  there  would  be  no  difference  between  the  menstrual  flux 
and  menorrhagia,  except  in  the  quantity  of  blood  which  might 
be  expended:  and,  consequently,  that  menorrhagia  is  nothing 
but  an  excessive  secretion  of  the  menstrual  fluid ;  or  that  the 
menstrual  fluid  is  nothing  but  proper  blood. 

Mr.  Hunter  declares,  "it  (the  menstrual  fluid,)  is  neither  si- 
milar to  blood  taken  from  a  vein  of  the  same  person,  nor  to  that 
which  is  extravasated  by  accident  in  any  other  part  of  the  body ; 
but  is  a  species  of  blood  changed,  separated,  or  thrown  off  from 
the  common  mass,  by  an  action  of  the  vessels  of  the  uterus  simi- 
lar to  that  of  secretion,  (see  p.  55,)  by  which  action  the  blood 
loses  the  principle  of  coagulation,  and,  I  suppose,  life."  Dr. 
Good1  observes  upon  this  subject,  that,  "as  this  distinction  has 
not  been  sufficiently  attended  to,  either  by  nosologists  or  physio- 
logists, many  of  the  diseases  occurring  in  the  present  arrange- 

'  Study  of  Medicine,  vol.  iv.  p.  30.    Amer.  Ed. 


152  MENORRHAQIA. 

ment,  (his  own,  under  Paramenia,1)  have  been  placed  by  other 
writers  under  a  genus  named  Menorrhagia,  (a  morbid  flow  of 
blood  alone,)  from  the  menstrual  vessels.  And  we  have  here  not 
only  a  wrong  doctrine,  but  the  formation  of  an  improper  genus ; 
for  menorrhagia  is,  correctly  speaking,  only  a  species  of  the 
genus  Hemorrhagia." 

We  have  just  intimated,  that,  as  we  are  at  present  ignorant  of 
the  agency  of  remedies  upon  the  different  portions  of  the  uterine 
system,  a  knowledge  whether  the  blood  expended  in  menorrhagia 
be  from  the  vessels  which  prepare  the  menstrual  fluid,  or  from  a 
distinct  set  of  vessels,  would  be  of  little  consequence  in  a  practi- 
cal point  of  view;  yet  the  time  may  arrive,  and  that  soon,  when 
such  knowledge  might  be  highly  useful.  For,  at  the  present  mo- 
ment, we  are  acquainted  with  the  influence  which  the  ovaria 
exert  over  the  internal  surface  of  the  uterus  in  the  production 
of  the  menstrual  fluid ;  and,  consequently,  that  it  may  be  essen- 
tial, in  the  various  deviations  in  the  formation  of  this  fluid,  that 
the  restorative  remedies  be  addressed  to  these  bodies ;  whereas, 
if  a  different  set  of  vessels  from  the  menstrual  yield  the  blood, 
the  cure  might  require  remedies  that  would  exert  an  influence 
upon  the  extreme  vessels  of  the  uterine  surface. 

At  first  sight,  it  may  appear  idle  to  anticipate  the  possession  of 
remedies  that  would  exert  an  exclusive  control  upon  each  por- 
tion of  the  uterine  system.  Yet  even  the  present  history  of  the 
Materia  Medica  will  justify  the  expectation.  The  ergot,  for  in- 
stance, manifests  its  action  upon  the  fibres  of  the  body  and 
fundus  of  the  uterus,  and  not  upon  the  neck ;  the  sugar  of  lead 
acts  upon  the  extremities  of  bleeding  vessels ;  the  spirits  of  tur- 
pentine upon  the  mucous  surfaces :  mercury  upon  the  salivary 
glands,  &c.  &c.  Is  it,  then,  unreasonable  to  hope  we  may  soon 
be  in  possession  of  substances,  whose  action  shall  be  confined  to 
the  ovaria  or  to  the  internal  surface  of  the  uterus  ?  for  until  we 
do  find  such  specifics,2  our  practice,  in  the  inordinate  flow  of  the 
menses,  and  in  menorrhagia,  will  be  rather  uncertain. 

1  "  Morbid  evacuation,  or  deficiency  of  the  catamenial  flux."     Amer.  Ed. 

1  Every  substance  which  can  exert  an  influence  upon  the  animal  system,  causes 
its  own  peculiar  mode  of  action;  and  from  what  we  already  know,  there  is  every 
reason  to  believe,  that  each  organ  belonging  to  the  human  fabric  has  appropriate 
stimuli  in  a  state  of  health,  or  counter-agents  in  a  state  of  disease,  among  the  va- 
ried productions  of  nature;  and  that  these  stimuli  or  counter-agents,  are  capable 
of  changing  the  mode  of  action  of  such  parts,  on  which  they  are  destined  to  act. 
If  this  be  true,  how  important  is  it  that  the  peculiar  action  of  every  substance 
should  be  closely  watched  when  administered  to  the  living  animal  ?  It  is  only  by 
such  attention  to  the  influence  of  medicines,  that  remedies  can  be  discovered,  and 
properly  classed;  and  it  is  by  the  same  kind  of  scrutiny  that  an  individual  article 
of  that  class  shall,  at  one  time,  or  occasion,  merit  a  preference  over  every  other 
individual  of  the  same  class.  To  prove  this,  we  need  but  refer  to  every  day's  ex- 
perience, in  the  choice  of  cathartics,  emetics,  astringents,  &c.,  when  prescribing 
for  the  body  in  a  state  of  disease. 


MENORKHAGIA.  153 

It  may  be  asked,  of  what  practical  value  would  the  knowledge 
be,  whether  the  fluid  expended  in  menorrhagia  be  an  increased 
secretion  of  the  menstrual  fluid  or  truly  a  hemorrhage?  We 
would  answer,  that  the  truth  is  always  of  consequence,  either  di- 
rectly or  indirectly;  and  that,  if  they  be  the  same  fluids,  the  dis- 
ease in  question  would  consist  of  a  morbid  condition  of  a  natural 
action ;  and  if  they  be  not,  as  we  believe  they  are  not,  the  menor- 
rhagic  discharge  would  consist  of  a  morbid  condition  of  some 
other  portion  of  the  uterine  surface,  than  that  which  furnishes  the 
menstrual  blood,  the  knowledge  of  which  may  lea,d  to  great  prac- 
tical results.  Be  this  as  it  may,  the  disease  is  of  such  frequency 
and  consequence,  as  to  render  a  complete  knowledge  of  its  mode 
of  treatment  highly  important.  We  shall,  therefore,  proceed 
to  give  a  history  of  this  disease,  together  with  the  mode  of  treat- 
ment. 

When  treating  of  the  "immoderate  flow  of  the  menses,"  we 
observed,  that  excess  of  discharge  must  be  considered  as  a  rela- 
tive term ;  and  that  we  should  rather  consider  the  consequences 
of  the  quantity,  than  the  quantity  itself.  But,  with  respect  to 
menorrhagia,  it  will  be  found  the  best  .practice  to  attempt  to  ar- 
rest it  in  limine :  we  have,  therefore,  for  many  years,  treated  this 
disease  as  one  that  would  most  probably  increase  if  neglected, 
though  the  hemorrhage  may  be  small  at  the  time. 

Gardien,1  however,  says,  that  "we  should  judge  less  by  the 
quantity  expended,  that  menstruation  is  immoderate,  than  by  the 
loss  of  strength  that  is  the  consequence  of  it."  This  advice,we 
have  agreed  would  be  correct,  if  the  discharge  were  that  of  the 
menstrual  blood ;  but  we  cannot  agree  it  would  be  proper  in 
menorrhagia.  We  have  just  declared  that  Gardien  had  con- 
founded these  two  conditions  of  the  uterus,  and  this  in  mere  com- 
pliance with  a  preconceived  notion ;  and  that  notion,  in  our  opi- 
nion, founded  on  no  better  ground  than  the  weight  of  authority.2 
Hippocrates  compared  the  purity  of  the  menstrual  blood  to  that 
of  an  immolated  victim ;  and  declared  it  would  coagulate  as 
quickly,  if  the  woman  were  in  good  health.  This  opinion  has 
been  copied  into  almost  all  the  books  of  medicine  since  that  time, 
and  handed  down  and  believed  by  many  at  this  moment.  Our 
own  inquiries  upon  this  subject,  and  they  may  strictly  be  called 
extensive,  have  constantly  led  to  an  opinion  contrary  to  that  en- 
tertained by  Hippocrates;  and  we  are  certain  that  this  discharge, 
when  in  a  state  of  health,  differs  widely  from  the  blood  of  hemor- 
rhage.8 

'Vol.  l,p.  2=9. 

*  "  L'homorrhagie  naturelle  qui  constitue  les  regies  est  art£riell«:  a  cette 
epoque  de  la  vie,  presque  toutes  les  h6morrhagies  sont  arterielles."  Vol.  1 ,  p. 
223.  In  this  quotation  it  is  perceived  that  he  calls  the  menstruous  action  a  he- 
morrhage, and  an  arterial  hemorrhage. 

'  See  p.  94. 


154  MENORRHAGIA. 

We  have,  in  our  definition  of  menorrhagia,  declared  it  to  be  a 
discharge  "of  fluid  blood,  or  coagula,  or  both;"  and  in  these  re- 
spects, it  differs  widely  from  the  product  of  the  menstrual  action. 
If  a  coloured  fluid  escape  from  the  vagina,  which  will  coagulate 
when  exposed  to  the  air,  or  if  it  be  expelled  in  form  of  coagula, 
we  no  longer  consider  this  the  healthful  process  termed  menstru- 
ation, but  the  disease  called  menorrhagia ;  and,  when  applied  to 
for  this  purpose,  we  prescribe  for  a  state  of  disease ;  for  it  is 
agreeable  to  observation,  that  when  this  condition  obtains,  the 
uterus  is  not  in  an  entirely  healthy  state.  And  we  may  urge,  as 
a  proof  of  this,  that  those  women  who  habitually  expel  coagula  to 
any  amount,  do  not  conceive  until  this  state  of  the  uterus  is 
changed. 

Women  who  live  indolently,  and  indulge  in  stimuli ;  who  use 
little  or  no  exercise ;  who  keep  late  hours ;  who  dance  inordi- 
nately ;*  who  are  intemperate ;  who  have  borne  many  children ; 
who  have  been  subject  to  febrile  affections ;  who  have  much  leu- 
corrhcea ;  who  are  too  prodigal  for  the  joys  of  wedlock  ;  who  are 
advancing  towards  the  non-menstrual  period ;  who  yield  too  rea- 
dily to  passions  or  emotions  of  the  mind,  are  those  most  obnox- 
ious to  menorrhagia. 

This  complaint  is  almost  always  announced  by  certain  unplea- 
sant feelings,  which  the  woman  after  awhile  recognises  to  be  the 
harbingers  of  this  hemorrhagy ;  such  as  lassitude,  and  especially 
of  the  limbs;  back-ache;  a  sense  of  fulness;  and  pressure  about 
the  region  of  the  uterus  ;  a  dragging  sensation  about  the  groin  ; 
frequent  inclination  to  make  water ;  chilliness  ;  a  variety  of  ner- 
vous symptoms ;  feverishness  ;  quick  pulse,  and  oftentimes  tense, 
full,  &c. ;  all  of  which  disappear,  or  are  much  moderated  so 
soon  as  the  discharge  takes  place.  This  discharge  is  almost 
always  the  true  menstrual  secretion  in  the  commencement ;  but 
it  is  either  arrested,  or  is,  more  properly  speaking,  confounded 
with  the  blood,  or  coagula,  which  now  make  their  appearance ; 
and  which  may  continue  a  longer  or  shorter  period;  and  of 
which  more  or  less  may  be  expended. 

It  may  take  place  without  any  premonition  ;  especially  if  the 
operation  of  a  moral  cause  has  produced  it ;  and  the  quantity 
thrown  out  may  be  so  moderate  as  to  induce  very  little  weakness, 
or  any  other  inconvenience,  save  that  which  arises  from  its  dura- 
tion ;  or  it  may  be  so  profuse,  as  to  suddenly  prostrate  the  strength, 
and  become  quickly  alarming.  It  may  continue  but  the  ordinary 
menstrual  period ;  or  it  may  persevere  for  many  days  beyond 
it.  It  rarely  ceases  suddenly ;  but  gradually  declines,  both  in 

1  Gardien  especially  condemns  the  "Waltz."  He  says  "II  n'en  est  point  .1e 
pins  propre  a  produire  cet  effet  que  cette  danse  voluptueuse  connue  sous  le  nom 
de  Walse."  Vol.  I.  296. 


MENORRHAQIA.  155 

quantity  and  in  the  intensity  of  its  colour,  several  days  before 
it  stops  altogether. 

When  it  has  continued  for  many  days  together,  it  becomes 
serous  towards  the  decline;  and  this  change  is  almost  always 
attended  with  an  unpleasant  odour;  sometimes  extremely  offen- 
sive, and  occasionally  even  acrid.  If  it  has  been  habitual  for 
some  time,  the  woman  becomes  pale,  feeble,  and  emaciated. 
The  breasts  lose  their  fulness,  and  become  flaccid.  Leucorrhoea 
is  almost  always  an  attendant ;  which  may  be  very  abundant, 
and  even  offensive.  The  digestive  organs  become  involved,  and 
betray  many  distressing  dyspeptic  symptoms.  Every  thing  turns 
sour  upon  the  stomach ;  the  bowels  become  constipated,  or  are 
urged  to  diarrhoea;  the  feet  swell;  and,  if  not  arrested,  dropsy 
may  ensue. 

There  are  evidently  two  conditions  of  this  affection;  one, 
where  the  whole  system  participates ;  and  plethora  may  exist,  or 
even  distinctly  formed  fever  may  be  excited,  just  before  the 
hemorrhage  takes  place.  In  this  case,  the  face,  the  eyes,  the 
spirits  all  partake  of  this  general  state  of  excitement;  nor  does 
this  condition  subside,  until  the  uterine  irritation  ceases.  The 
other  seems  to  consist  of  a  mere  local  determination  to  the  uterus, 
producing  an  engorgement  of  this  organ,  but  which  does  not  im- 
plicate the  general  system,  except  from  the  waste  of  strength  it 
occasions,  when  the  discharge  is  profuse  or  long-continued. 

Most  writers  on  the  subject  of  hemorrhages  have  divided  them 
into  active  and  passive ;  but  there  is  great  room  to  question  at 
least  the  propriety  of  this  mechanical  distinction,  if  there  be  not 
sufficient  ground  to  reject  it  altogether. 

Broussais  powerfully  opposed  the  doctrine  of  passive  hemor- 
rhages :  he  contended,  that,  in  all  cases,  there  existed  an  irrita- 
tion in  the  part  that  yielded  the  blood;  and  that  weakness,  with- 
out irritation,  could  no  more  produce  hemorrhage  than  inflam- 
mation. It  is  supposed  by  those  who  advocate  the  doctrine  of 
passive  hemorrhage,  that  the  expended  blood  proceeds  from  the 
relaxed  or  partially  paralyzed  exhalants.  But  he  contends  that 
this  cannot  be  the  case,  since  Bichat,  and  other  modern  physio- 
logists, appear  to  have  proved,  that  after  the  blood  arrives  in -the 
capillary  system,  it  is  no  longer  subject  to  the  action  of  the 
heart.  If  this  be  admitted,  where  is  the  power  that  can  force 
the  blood  into  these  orifices  ? 

Dr.  Caldwell,1  in  a  note  on  Cullen's  division  of  hemorrhagies 
into  active  and  passive,  observes,  that  this  distinction  "is  utterly 
unfounded,  and  ought  to  be  rejected  from  pathological  science. 
The  phraseology  leads  to  a  physiological  error.  The  expression, 
'passive  hemorrhagy,'  as  applied  to  living  matter,  is  a  gross 

1  Ed.  of  Cullen's  Practice,  p.  734. 


156  MENORRHAGIA. 

misnomer.  During  life,  no  hemorrhage  can  possibly  be  passive. 
Blood  flows  from  the  vessels  that  contain  it,  at  least  in  part,  by 
means  of  the  action  of  that  vessel.  Now,  is  it  possible  for  such 
action  to  cease,  otherwise  than  by  the  cessation  of  life  in  the  part? 
But  the  cessation  of  life  is  the  commencement  of  gangrene.  A 
hemorrhagy  really  passive,  therefore,  cannot  take  place,  except 
from  gangrenous  vessels.  But  from  such  vessels,  unless  they  be 
very  large,  blood  does  not  flow  at  all.  The  reason  is  obvious. 
They  act  on  the  blood  which  they  contain  like  dead  matter;  and 
we  well  know,  that  the  action  of  dead  matter  on  blood  forces  it 
to  coagulate.  Hence,  in  the  vessels  of  a  gangrenous  part,  the 
blood  does  coagulate,  and  prevents  the  hemorrhagy  that  would 
otherwise  ensue."1 

"Every  hemorrhagy,  therefore,  that  does  or  can  take  place 
from  the  living  body,  is  really  an  active  one.  It  arises,  not  from, 
the  absolute  want  of  action  in  the  part,  but  from  its  wrong  action. 
The  vessels  dilate,  or  rather  contract  and  dilate  alternately,  when 
they  ought  to  contract  only,  and  thus  prevent  the  escape  of  the 
blood  they  contain." 

For  these  reasons,  and  because  we  have  never  been  able  to 
perceive  any  practical  benefit  from  the  division  of  hemorrhagies 
into  active  and  passive,  we  shall  consider  the  hemorrhagy  of 
which  we  are  treating  always  to  be  of  the  active  kind. 

We  have  stated  above,  that  there  are  two  varieties  of  menor- 
rhagia;  and  that  the  first  owes  its  character  to  the  plethoric  con- 
dition of  the  blood  vessels,  and  the  general  participation  of  the 
system :  hence,  the  fevered  cheek ;  the  brilliant,  and  sometimes 
engorged  eye;  the  quick,  hard  pulse;  pain  and  other  uneasiness 
about  the  back  and  uterine  region,  just  before  the  hemorrhage 
takes  place;  as  well  as  the  peculiar  character  of  the  fluid  which 
is  discharged. 

The  blood  discharged  in  this  variety  of  menorrhagia  is  sure  to 
betray  the  general  condition  of  the  system;  for  it  is  always  found 
rather  florid,  dense,  with  but  little  serum,  and  much  disposed  to 

1  It  seems  to  be  a  law  of  the  system,  that  the  tendency  of  the  blood  to  coagu- 
late^  is  in  proportion  to  the  diminution  of  vital  energy.  This  law  is  one  of  great 
consequence  and  efficacy,  in  those  threatening  lesions  of  the  body,  called  hemor- 
rhagies; for,  oftentimes,  death  would  instantly  ensue  from  these  causes,  did  not 
the  blood,  by  a  sudden  coagulation,  prevent  the  farther  waste  of  this  fluid.  .This 
disposition  to  coagulate  is  almost  certain,  when  the  powers  of  life  are  put  sud- 
denly upon  the  wane  from  the  expenditure  of  blood,  by  inducing  a  state  of  syn- 
cope. Now,  syncope  is  a  kind  of  counterfeit  death;  all  the  vital  energies  are 
suspended  for  awhile,  almost  as  effectively  as  if  death  had  really  taken  place,  and 
the  law  of  coagulation  is  put  in  operation,  by  coagula  forming,  and  thus  putting 
a  stop  to  farther  bleeding.  These  facts  are  well  ascertained.  Therefore,  when 
syncope  takes  place,  the  blood  vessels  are  almost  in  a  state  of  death,  or  at  least, 
of  temporary  paralysis;  they  no  longer  propel  by  acting  upon  their  contents; 
consequently,  their  contents  remain  quiescent.  But,  agreeably  to  the  doctrine 
of  passive  hemorrhage,  the  blood  should  now  flow  faster,  since  the  vessels  are  in 
a  state  of  the  greatest  possible  relaxation. 


MENORRHAGIA.  157 

coagulate.  The  quantity  evacuated  will,  of  course,  differ  in  dif- 
ferent individuals ;  but,  whatever  may  be  the  quantity,  it  is  sure 
to  present  the  qualities  just  named. 

This  hemorrhagic  disposition  of  the  uterus  may  take  place  at 
any  moment  of  the  menstruating  period;  and  at  any  age  within 
that  limit.  But  the  vigorous  and  plethoric,  who  are  liable  to  the 
influence  of  the  exciting  causes,  are  more  subject  to  it  than  the 
feeble-pulsed,  and  those  who  do  not  encounter  such  causes. 
Thus,  we  find  women  of  cities  more  obnoxious  to  menorrhagia 
than  those  of  the  country;  because  the  physical  and  moral 
causes,  which  tend  to  produce  that  condition  of  the  system,  are 
applied  with  more  force  and  certainty  to  the  former  than  to  the 
latter. 

But  independently  of  the  causes  which  may  tend  to  induce  a 
general  plethoric  disposition  of  the  body,  there  are  some  which 
act  by  creating  a  local  congestion  of  the  uterus  itself.  Thus,  the 
frequency  of  this  complaint  among  the  women  of  Holland,  is  at- 
tributed to  the  almost  constant  use  of  foot  stoves,  and  the  inor- 
dinate drinking  of  hot,  thin  liquids,  as  tea  and  coffee;  they  are 
also  indolent  and  luxurious.1  Dancing  immoderately,  and  then 
permitting  the  body  to  cool  suddenly;  tight-lacing;  ill-protected 
lower  extremities ;  frequent  use  of  demi-baths ;  excess  of  venery, 
&c.,  may  be  considered  as  the  most  common  of  such  causes. 

The  most  frequent  of  the  exciting  causes  are  all  such  as  may 
suddenly  augment  the  force  of  the  circulation,  and  the  motion  of 
the  heart;  or  such  as  shall  tend  to  have  a  direct  action  upon  the 
uterus  itself.  Of  the  first  kind,  is  an  over-stimulating  diet ;. pas- 
sions or  emotions  of  the  mind;  violent  exercise,  or  exertion  of  a 
sudden  kind.  Of  the  second  kind,  emmenagogue  medicines,  as 
the  tincture  of  cantharides,  aloes,  savin,  immoderate  venery, 
especially  during  the  flow,  &c. 

The  indications  of  cure  in  the  first  species,  may  be  readily  de- 
duced from  the  premonitory  and  accompanying  symptoms. 
They  all  show  the  plethoric  condition  of  the  system  in  general, 
and  of  the  uterus  in  particular;  therefore,  the  means  to  be  em- 
ployed to  prevent  this  hemorrhagy,  will  consist,  first,  of  such 
as  are  applied  during  the  absence  of  the  hemorrhagy;  and,  se- 
condly, those  during  the  period  of  the  discharge.  For  the  first, 
The  predisposing  causes  should  be  withdrawn  as  effectually  as 
possible,  by  obliging  the  patient  to  renounce  her  indolent  habits ; 
by  taking  regular  and  well  adapted  exercise  in  proper  weather 
in  the  open  air ;  to  live  upon  a  milk  and  vegetable  diet ;  to  abstain 
from  all  spirituous  and  fermented  liquors;  to  indulge  in  no  stimu- 
lating articles  of  diet,  as  spices,  or  other  condiments;  to  keep  the 
bowels  regular  or  even  a  little  loose ;  to  sleep,  (and  that  not  too 

'Dr.  Rush,  MS.  Lectures,  Leake,  Gardien,  &c. 


158  MENORRHAGIA. 

long  at  a  time,)  in  a  cool  room,  upon  a  hard  bed,  and  without 
too  many  bed-clothes,  or  even  curtains ;  to  keep  the  feet  and 
legs  warm;  and  occasional  blood-lettings,1  &c. 

To  shun  the  exciting  causes  enumerated  above,  with  the  most 
scrupulous  care. 

During  the  flow,  the  first  object  is  to  diminish  the  force  of  the 
circulation  by  blood-letting  from  the  arm,  rest,  a  horizontal  pos- 
ture, cool  air,  and  cold  drinks ;  secondly,  to  reduce  the  quantity 
of  the  discharge,  by  such  means  as  favour  the  contraction  of  the 
vessels  concerned  in  the  hemorrhage,  and  favour  the  coagulation 
of  the  blood.  Of  the  remedies  which  are  calculated  to  fulfil  these 
useful  purposes,  the  sugar  of  lead  seems  at  present  to  stand  fore- 
most: it  should  be  given  in  liberal  doses,  often  repeated,  if  ne- 
cessary; but  always  guarded  with  opium.  The  following  is  our 
usual  formula: — 

R.  Acetat.  plumb.  Qij. 

Gum  opii.  gr.  iv.     M.  f.  pil.  xij. 

One  of  these  to  be  given  every  half  hour,  hour,  two  hours,  or  more  seldom,  as  the 
necessity  may  be." 

1  Blood-letting  should  always  be  employed  in  the  intervals,  in  cases  of  this 
kind,  whenever  the  pulse  is  active;  and  it  must  be  repeated  as  long  as  the  pulse  is 
tense,  irritable,  or  full.  The  best  time  to  abstract  blood,  we  think,  is  a  few  days 
before  the  discharge,  provided  the  pulse  be  active  at  this  time:  if  it  be  not,  let  it 
be  watched,  and  when  it  is  found  to  be  acquiring  strength,  let  the  blood  be  taken 
then,  and  in  sufficient  quantity  to  reduce  both  the  size  and  vigour  of  the  artery; 
for  bleeding  is  useful  in  such  cases,  in  proportion  to  the  contraction  it  produces  in 
the  vessels.  If  the  pulse  rise  only  near  the  period  for  the  renewal  of  the  hemor- 
rhagy,  blood  must  then  be  abstracted,  by  all  means,  and  in  larger  quantity  than  at 
the  other  periods  just  indicated.  For  if  this  direction  be  not  attended  to,  very 
little  advantage  will  be  derived  from  the  operation,  as  the  desired  object,  (the 
contraction  of  the  vessels,)  will  scarcely  take  place,  as  those  of  the  uterus  are  so 
insulated,  and  independent  of  those  of  the  general  system. 

I  have  thought  I  derived  much  advantage,  at  these  times,  from  the  application 
of  leeches  to  the  small  of  the  back;  for  eight  or  ten  ounces  abstracted  by  them, 
seems  to  have  more  control  over  the  uterine  circulation,  than  double  that  quantity 
taken  from  the  arm. 

*  Dr.  Porta  recommends  "tannin"  in  menorrhagia,  in  doses  of  three  grains, 
every  three  hours;  and  is  led  to  the  following  conclusions  in  regard  to  its  use: — 

1.  That  whenever  the  uterus  is  the  seat  of  irritation,  which  gives  rise  to  an 
active  or  hypersthenic  flooding,  and  also  when  this  discharge  depends  upon  a 
chronic  metritis,  this  medicine  acts  specifically  upon  the  uterus. 

2.  But  when  acute  metritis  gives  rise  to  menorrhagia,  the  inflammation  must 
be  subdued  by  copious  and  sufficient  blood-lettings. 

3.  But  when  menorrhagia  proceeds  from  any  organic  alterations  in  the  uterus, 
this  medicine  has  no  efficacy. 

4.  That  a  preference  should  always  be  given  to  this  medicine  in  the  treatment 
of  menorrhagia,  as  it  is  very  prompt  in  its  effects:  it  produces  no  unpleasant 
symptoms ;  and  the  stomach  bears  it  well  even  in  a  state  of  irritation. — Archiv. 
Gen.  from  the  Annali  Univ.  de  Med.  April,  1827. 

It  may  be  well  to  observe,  that  "  tannin  "  in  its  pure  state,  is  very  difficult  to 
procure,  and,  consequently,  in  that  condition  cannot  be  well  employed,  in  general 
practice.  It  certainly  abounds  in  the  Rad.  rhatanse;  therefore  the  extract  of  this 
substance  is  perhaps  as  good  a  form  as  any  we  can  employ.  We  have  already 
mentioned  this  substance,  when  treating  of  the  decline  of  the  menses,  page  147. 


MBNORKHAGIA.  159 

If  this  make  the  stomach  sick,  or  if  nausea  and  vomiting  attend, 
which  sometimes  happens,  it  may  be  administered  in  the  form  of 
enema,  as  follows :  a  scruple  of  the  acetate  dissolved  in  two  ounces 
of  warm  water,  to  which  must  be  added  a  tea-spoonful  of  lauda- 
num. Should  this  be  discharged  soon,  it  may  be  repeated. 

We,  however,  from  late  experience,  prefer  the  vinous  tincture 
of  the  secale  cornutum ;  twenty  drops  in  a  little  sweetened  water 
every  hour  until  uterine  pains  are  produced.  The  medicine  is 
then  suspended  until  this  irritation  passes  off:  it  is  then  to  be  re- 
peated until  similar  effects  are  produced ;  but  given  at  longer  and 
longer  intervals. 

Cold  applications,  consisting  of  equal  parts  of  whiskey  or 
brandy,  and  vinegar,  should  be  applied  over  the  pubes,  and  re- 
newed as  soon  as  it  becomes  warm.  In  warm  weather,  the  ad- 
dition of  ice  is  very  important.  The  best  mode  of  applying  the 
cold  mixture  is  by  cloths  wrung  out  of  the  mixture;  or  by  means 
of  a  large  bladder  partially  filled.  If  the  latter  be  used,  cold 
water  is  as  good  as  the  mixture  just  named,  as  the  fluid  does  not 
come  in  contact  with  the  skin;  its  whole  virtue  being  in  its  cold- 
ness. 

Late  experience,  however,  teaches  me  to  consider  the  tinct. 
secale  cornutum  vin.,  as  the  remedy  most  to  be  relied  on.  If 
given  in  tea-spoonful  doses,  morning,  noon  and  evening,  in  some 
sugar  and  water  until  the  discharge  again  makes  its  appearance, 
it  will  be  found  to  have  abated  the  ensuing  discharge  very  much ; 
and  if,  after  this,  the  discharge  should  continue,  the  tincture  must 
be  continued.  Care  must  be  taken  that  the  drug  is  fresh  as  pos- 
sible ;  as  it  is  ascertained  that  this  remedy  will  not  preserve  its 
activity  more  than  two  years,  after  being  kept  dry  and  in  a  ground 
glass  stopper  bottle. 

The  plan  just  detailed  is  intended  only  for  such  cases  as  are 
attended  by  a  profuse  and  threatening  discharge ;  for,  in  ordinary 
cases,  the  sugar  of  lead,  as  prescribed  above,  answers  every  pur- 
pose without  the  cold  application.  We  deem,  however,  the  other 
caution  important,  even  in  very  moderate  cases ;  as  very  slight 
errors  will  sometimes  create  a  great  deal  of  mischief.  Rest,  cool 
air,  a  very  low  diet,  and  cold  drinks,  should  be  always  insisted 
on,  if  we  expect  a  permanent  cure,  even  in  cases  where  the  pa- 
tient does  not  think  it  important  to  lie  by.  Where  the  discharge 
is  very  profuse  and  alarming,  which  sometimes  happens,  even 
with  young  girls,  but  more  especially  with  women  pretty  well 
advanced  in  life,  and  the  means  above  recommended  have  not 
proved  successful,  the  tampon  must  be  had  recourse  to. 

The  variety  we  have  just  described  is  generally  of  much  easier 
management  than  the  second;  which  consists  "in  a  mere  local 
determination  to  the  uterus,  producing  an  engorgement  of  this 
organ ;  but  which  does  not  implicate  the  general  system,  except 


160  MENORRHAGIA. 

from  the  waste  of  strength  it  occasions,  when  the  discharge  is 
profuse,  or  long  continued." 

The  variety  now  under  consideration  is  most  common  to  wo- 
men of  an  irritable  and  feeble  constitution ;  and  where,  agreeably 
to  Gardien,  there  exists  an  accumulation  of  vital  power  towards 
the  uterus. 

This  variety,  like  the  one  just  spoken  of,  is  accompanied  by 
some  pain  and  heaviness  in  the  uterine  region ;  heat  and  some- 
times itching  in  the  pudendum.  The  pulse  is  small,  and  rather 
frequent;  the  extremities  disposed  to  become  cold;  the  face  pale, 
and  sometimes  cachectic;  the  appetite  feeble ;  the  tongue  fre- 
quently found  furred,  especially  in  the  morning ;  palpitation  of 
the  heart ;  and  respiration  hurried  upon  motion,  &c. 

The  indications  in  this  variety  are,  to  destroy  or  diminish 
this  congestive  tendency  of  the  uterus ;  and  to  moderate  or  in- 
terrupt the  unnatural  discharge. 

The  first  indication  is  to  be  fulfilled  by  equalizing  the  circula- 
tion as  much  as  possible,  by  determining  it  towards  the  surface; 
by  well-regulated  exercise;  by  wearing  flannel  next  the  skin; 
by  keeping  the  lower  extremities  warm ;  by  a  nutritive  and  easily 
assimilated  diet;  abstaining,  however,  from  stimulating  condi- 
ments and  drinks ;  by  preventing  constipation,  by  even  purging 
with  aloetic  medicines;1  by  diverting  the  current  of  blood  to 
some  neighbouring  part,  by  dry  cupping  the  small  of  the  back, 
and  blistering  the  inner  side  of  the  thighs ;  and  by  the  application 
of  leeches  to  the  groin,  or  inner  part  of  the  thighs.  This  last  re- 
medy is  found  to  be  particularly  useful,  when  used  three  or  four 
days  before  the  expected  sanguineous  eruption ;  three  or  four 
ounces  abstracted  in  this  manner  is  every  way  sufficient.  The 
mustard  bath  is  a  very  good  remedy  in  such  cases.  Emetics, 
and  especially  the  ipecacuanha  emetics,  are  thought  to  be  useful 
in  this  variety  of  menorrhagia ;  they  were  first  proposed  by  Dr. 
Bryan  Robinson  for  hemorrhagy,  and  have  since  been  recom- 
mended in  menorrhagia;  but  of  these  we  can  say  nothing  decisive 
from  experience.  If  at  all  useful,  in  such  cases,  it  must  be  just 
before  the  menstrual  eruption ;  for,  during  the  flow,  we  never  re- 
member to  have  seen  vomiting  abate  the  discharge  when  it  came 
on  spontaneously,  though  it  may  have  been  pretty  severe.  Taking 
a  grain  of  the  sugar  of  lead  with  a  little  opium,  three  or  four 
times  a  day  in  the  absence  of  the  discharge ;  or  drachm  doses  of 

1  We  have,  in  several  cases  of  menorrhagia,  in  women  somewhat  advanced  in 
life,  found  great  advantage  from  the  hiera  picra  as  a  cathartic :  it  may  be  used 
agreeably  to  the  following  formula  : — 

R.  Hiera  Picra,        -         -        gj. 
Sapo.  Venet.        -        -        gr.  viij. 
Syr.  Rhsei.  q.  s.  m. — f.  pil.  xx. 

One  or  two  of  these  taken  every  night,  until  the  bowels  are  found  free.     See  p. 
145. 


SIGNS  ACCOMPANYING  PREGNANCY.  161 

the  tincture  of  rhatany,  or  the  extract,  as  directed  at  page  147, 
will  be  found  highly  useful. 

To  fulfil  the  second  indication,  the  means  are  precisely  the 
same  as  recommended  in  the  first  variety;  with  this  exception, 
that  if  the  discharge  be  long  continued,  we  may  employ  the  dry 
cupping  and  apply  blisters. 

In  both  varieties,  we  have  often  found  decided  advantage  from 
injections  per  vaginam,  made  of  the  solution  of  the  acetate  of  lead, 
of  sufficient  strength — that  is,  two  or  more  drachms  to  a  pint  of 
lukewarm  water.  Half  of  this,  or  one  third,  may  be  thrown  up 
the  vagina  by  means  of  a  syringe,  three  or  four  times  a  day. 

In  all  cases  of  menorrhagia,  opium  is  found  highly  useful,  when 
combined  with  small  portions  of  ipecacuanha ;  and  should  always 
be  exhibited,  as  soon  as  the  pulse  will  bear  its  stimulus.  It 
should  be  certainly  given  at  night,  if  pain  prevents  sleep ;  or 
even  during  the  day,  if  necessary. 

Gardien  makes  a  third  variety  of  menorrhagia;  namely,  "a 
spasmodic."  Of  this  variety  I  can  say  nothing ;  nor  do  I  believe 
in  its  existence;  the  only  evidence  of  the  species,  agreeably  to 
him,  is,  that  menorrhagia  is  sometimes  relieved  by  opium,  or 
other  antispasmodics. 


CHAPTER  VIII. 

OF  THE  SIGNS  WHICH  USUALLY  ACCOMPANY  PREGNANCY. 

IN  a  work  treating  exclusively  of  the  diseases  peculiar  to  the 
female,  we  have  thought  it  important  that  the  inexperienced  prac- 
titioner should  be  well  acquainted  with  what  are  termed  the  ra- 
tional signs  of  pregnancy;  and  for  the  following  reasons: — 

1st.  Because  pregnancy  often  influences  our  prescriptions,  in 
both  the  acute  and  chronic  diseases  that  may  accompany  this 
condition. 

2d.  Because  the  physician's  opinion  may  decide  the  fate  of  a 
female  in  a  court  of  justice  when  she  wishes  to  take  advantage  of 
the  privileges  which  pregnancy  claims,  when  she  may  have  for- 
feited her  life  to  the  laws  of  her  country  by  her  crimes.  Or, 

3d.  Where  the  duration  of  human  gestation  may  involve  the 
character  or  property  of  individuals. 

Therefore  the  value  of  the  signs  of  pregnancy  should  be  as  well 

ascertained  as  the  nature  of  things  will  permit,  that  error  may 

not  be  committed  in  our  prescriptions ;  and  that  the  innocent  may 

not  be  injured,  or  the  guilty  absolved;  consequently,  in  a  medico- 

11 


*          4 

162  SUPPRESSION    OP    THE   MENSES. 

legal  point  of  view,  a  knowledge  of  the  symptoms  about  to  be 
considered,  is  every  way  of  great  importance. 

As  soon  as  impregnation  takes  place,  various  parts  sympathize, 
either  directly  or  indirectly,  with  this  condition  of  the  ovarium. 

These  sympathies,  or  disturbances,  are  generally  so  uniform  in 
their  nature,  and  so  regular  in  their  appearance,  that  they  have 
been  considered  as  evidences  of  pregnancy:  the  first,  and  most 
usual,  is  the  interruption  of  the  menstruous  discharge;  secondly, 
nausea,  and  vomiting ;  thirdly,  enlargement  of  the  breasts ;  fourth- 
ly, the  areolse  round  the  nipples ;  fifthly,  the  secretion  of  milk ; 
sixthly,  the  enlargement  of  the  abdomen;  seventhly,  the  increased 
size  of  the  uterus;  eighthly,  pouting  out  of  the  navel:  ninthly, 
spitting  of  white  frothy  mucus ;  tenthly,  salivation. 

Although  almost  ev6ry  pregnancy  has  nearly  the  whole,  or  the 
greater  part  of  the  signs  we  have  just  enumerated,  yet  their  union 
may  not,  in  a  given  individual  case,  so  positively  decide  this  con- 
dition as  to  render  it  free  from  all  doubt ;  especially  where  the  sub- 
ject may  become  an  object  of  judicial  proceeding ;  and  where  life, 
character,  or  property,  may  be  involved  in  the  consideration. 
On  this  account,  chiefly,  we  will  spend  a  few  moments  on  each 
of  these  reputed  signs  of  pregnancy. 


SECT.  I. — 1.  Suppression  of  the  Menses. 

Few  signs  of  pregnancy  are  more  equivocal  than  the  suppres- 
sion of  the  menses,  and  should  never  be  relied  on,  farther  than 
that  sign  is  entitled  to.  Dr.  Rigby  is  very  emphatic  on  this  sub- 
ject, in  his  System  of  Midwifery;  (p.  97,)  he  says,  "The  diag- 
nosis of  pregnancy  is  a  subject  well  worthy  of  the  student's  most 
serious  attention ;  for  he  will  of  course  be  liable,  when  in  prac- 
tice, to  be  called  to  give  his  evidence  before  a  court  of  justice, 
under  circumstances,  when  the  responsibility  will  ever  be  of  the 
most  serious  and  not  unfrequentty  of  the  most  fearful  nature,  the 
more  so,  as  the  old  custom  of  impanelling  a  jury  '  of  twelve  ma- 
trons '  to  determine  whether  the  woman  be  quick  with  child,  has 
fallen  deservedly  into  disrepute."  "Numerous  cases  are  on  re- 
cord where  a  false  diagnosis  in  women  convicted  of  capital  of- 
fences, has  led  to  the  most  lamentable  results,  and  where  dis- 
section of  the  body  after  death  has  shown  that  she  was  pregnant. 
A  case  is  related  by  Baudelocque  of  a  French  countess,  impri- 
soned during  the  French  revolution,  who  was  accused  of  carrying 
on  a  treasonable  correspondence  with  her  husband,  an  emigrant ; 
she  was  ordered  to  be  examined  by  two  of  the  best  midwives  in 
Paris,  and  they  declared  her  not  pregnant.  She  was  accord- 
ingly guillotined,  and  her  body  taken  to  the  School  of  Anato- 
my, where  it  was  opened  by  Baudelocque,  who  found  twins  in 


SUPPRESSION    OF    THE    MENSES.  163 

the  fifth  month  of  pregnancy." — Dr.  Rigby's  Syst.  of  Midwifery, 
p.  98.     Am.  Ed. 

The  suppression  of  the  menses,  in  a  married  woman,  or  in  a 
woman  who  has  had  illicit  commerce  with  a  man,  may  justly 
give  rise  to  the  suspicion  that  impregnation  has  taken  place; 
and,  as  a  general  sign,  may  safely  be  looked  upon  as  one  of  the 
most  unequivocal  that  may  present  itself;  yet  a  variety  of  causes, 
independently  of  pregnancy,  may  produce  the  same  effect,  both 
in  the  married  and  in  the  unmarried  woman :  1st.  Exposure  to 
cold  and  damp  at  the  time  the  menses  are  about  to  appear,  or 
immediately  after  they  have  shown  themselves.  2d.  Certain 
chronic  affections,  as  phthisis  pulmonalis,  scirrhous  liver,  or 
other  visceral  obstructions.  3d.  The  operation  of  certain  power- 
fully depressing  passions,  or  emotions  of  the  mind;  some  imper- 
fection in  either  the  ovaries  or  the  uterus  itself.  4th.  Accidents 
by  falling,  or  severe  blows ;  and,  lastly,  the  precocious  cessation 
of  this  function.1 

If,  then,  the  absence  of  the  menses  do  not  positively  evince 
pregnancy,  will  their  presence  prove  that  it  does  not  exist  ?  This 
question  would,  unquestionably,  be  answered  in  the  affirmative 
by  Dr.  Denman,  and,  perhaps,  many  others ;  not  because  they 
have  not  seen  coloured  discharges  from  the  vagina  during  preg- 
nancy; but  because,  from  a  preconceived  notion  of  the  functions 
of  the  uterus,  they  deny  these  discharges  to  be  menstrual. 

In  declaring  women  may  menstruate  after  impregnation,  I 
have  no  favourite  hypothesis  to  support ;  nor  am  I  influenced  by 
any  affectation  or  vanity  to  differ  from  others ;  neither  do  I  be- 
lieve I  am  more  than  ordinarily  prone  to  be  captivated  or  misled 
by  the  marvellous ;  for  I  soberly  and  honestly  believe  what  I  say, 
and  pledge  myself  for  the  fidelity  of  the  relation  of  the  cases  I 
adduce  in  support  of  my  position. 

Nothing  can  be  more  vague  and  unsatisfactory  than  Dr.  Den- 
man's  definition  of  menstruation:  namely,  "from  the  uterus  of 
every  healthy  woman,  who  is  not  pregnant,  or  who  does  not 
give  suck,  there  is  a  discharge  of  blood,  at  certain  periods,  from 
the  time  of  puberty  to  the  approach  of  old  age."  Now,  from 
this  definition  it  would  necessarily  follow,  that  if  a  woman  men- 
struate, she  must  be  in  good  health ;  but  the  experience  of  every 
day  is  against  this  conclusion.  Again,  if  a  woman  have  a  dis- 
charge of  blood  while  she  is  suckling,  she  must,  by  the  terms  of 
this  definition,  be  either  no  nurse,  or  this  discharge  is  not  men- 
struous  blood.  Dr.  Denman  would  certainly  agree  to  this  last 

1  Dr.  Lacock  relates  a  remarkable  case  of  this  kind,  in  which  a  young  'lady 
received  a  fall  down  some  steps  while  the  menses  were  flowing,  by  which  they 
were  instantly  arrested,  and  continued  to  be  so  during  a  considerable  time.  La- 
cock  on  Hysteria.  See  also  note,  p.  113.  I  saw,  as  I  mentioned,  a  similar  in- 
stance. 


t* 

SUPPRESSION    OF    THE    MENSES. 

deduction,  but  what  proof  has  he  to  support  this  belief?  So  far 
as  my  own,  and  the  experience  of  many  others  go,  I  should  say 
none.  I  wish  to  be  understood  to  mean,  whenever  I  use  the 
terms,  menstruous  discharge,  menstruous  blood,  menses,  or  any 
other  designation,  that  legitimate  discharge  from  the  uterus, 
which  would,  under  the  best  circumstances  of  health  in  general, 
or  condition  of  the  uterus  in  particular,  constitute  this  important 
function  in  its  most  perfect  form.  I  do  not  mean  to  include  dis- 
charges of  blood,  properly  so  called,  and  properly  so  being,  as 
eoming  within  my  views  and  meaning  of  the  above  terms.  I 
employ  the  terms  named  above  to  express  the  result  of  a  peculiar 
action  of  the  internal  surface  of  the  uterus,  but  which  differs 
widely  from  the  common  circulating  fluid  called  blood;  and  pre- 
cisely what  Dr.  Denman  wishes  to  be  understood  to  mean,  when 
he  speaks  of  "menstruation." 

The  only  argument  adduced  by  Dr.  Denman  in  support  of  his 
hypothesis,  is,  "that,  if  a  woman  menstruate  while  pregnant, 
she  must  very  often  miscarry,  as  a  part  of  the  ovum  must  neces- 
sarily be  detached  from  the  uterus  at  each  period."  I  would 
ask,  why  a  part  of  the  ovum  must  necessarily  be  detached  to 
give  issue  to  this  discharge  ?  I  see  no  reason  why  this  should 
be  so ;  as  I  am  persuaded  that  this  can  happen  without  any  such 
consequence.  Dr.  Hunter,  Dr.  Denman  himself,  Mr.  Burns, 
Baudelocque,-  &C.,1  all  declare,  that  for  the  first  two  or  three 
months,  the  inferior  portion  of  the  uterus,  and  more  especially 
the  neck,  are  not  always  occupied  by  the  decidua,  but  are  left 
as  free,  and  as  unembarrassed,  as  before  impregnation ;  of  this  I 
have  no  doubt ;  and  it  is  from  this  unoccupied  portion,  that  the 
menstruous  discharge  takes  place. 

If  it  be  said,  that  this  surface  is  insufficient  in  extent  to  yield 
the  quantity  that  is  ordinarily  discharged,  I  would  answer :  First, 
I  am  not  contending  for  the  quantity,  but  the  quality  of  the  eva- 
cuation. And  I  admit,  that,  when  this  evacuation  takes  place 
during  pregnancy,  it  is  not  so  abundant  as  it  "usually  is  under 
other  circumstances.  Second.  That  the  following  fact  will  show, 
how  capable  a  small  healthy  portion  of  the  internal  surface  of 
the  uterus  is,  of  yielding  a  quantity  of  menstruous  blood.  My 
friend,  Dr.  Coxe,  gave  me  a  diseased  uterus,  in  the  cavity  of 
which  there  was  a  healthy  portion  of  surface,  not  exceeding  in 
size  a  common  thumb-nail ;  and  from  this  surface  was  yielded, 
at  every  menstruous  period,  a  quantity  of  fluid ;  and  which,  as 
far  as  could  be  detected  by  its  sensible  properties,  was  of  a  per- 
fectly healthy  quality. 

1  "  En  general,  elles,  (les  regies,)  se  suspendent  durant  la  grossesse,  et  1'allaite- 
ment;  mais  il  est  des  cas  ou  leur  ecoulement  continue  dans  ces  circonstances;  re- 
lativement  a  la  grossesse,  il  se  borne  ordinairement  aux  premiers  mois,  rarement 
se  soutient  il  jusqu'  a  1'accouchement." — Frank. 


SUPPRESSION    OF    THE    MENSES.  165 

Again,  I  well  know  a  number  of  women  who  habitually  men- 
struate during  pregnancy,  until  a  certain  period;  but  when  that 
time  arrives,  menstruation  ceases  ;  several  have  menstruated  un- 
til the  second  or  third  month  ;  others  longer  ;  and  two  until  the 
seventh  month ;  the  last  two  were  mother  and  daughter.  I  am 
certain  there  was  no  mistake  in  the  cases  to  which  I  now  refer. 
My  interrogatories  were  numerous,  and  the  answers  bore  all  the 
marks  of  candour :  first,  the  menses  were  regular  in  their  returns ; 
not  suffering  the  slightest  derangement  from  the  impregnated 
condition  of  the  uterus ;  secondly,  from  two  to  five  days  were 
employed  for  their  completion ;  thirdly,  the  evacuation  differed 
in  no  respect  from  the  discharge  in  ordinary;  except,  they 
thought  it  less  abundant ;  fourthly,  there  were  no  coagula  in  any 
one  of  these  discharges ;  consequently,  it  could  not  be  the  com- 
mon blood,  or  the  blood  of  hemorrhagy  ;  fifthly,  in  the  two  pro- 
tracted cases,  the  quantity  discharged  regularly  diminished  after 
the  fourth  month,  a  circumstance  not  perhaps  difficult  of  ex- 
planation. I  may  also  cite,  in  favour  of  my  position,  the  au- 
thority of  Heberden,  Hosack,  and  Francis.1 

With  regard  to  nurses  menstruating,  every  accoucheur  must 
be  familiar  with  the  fact,  as  it  is  of  frequent  occurrence ;  happen- 
ing ten  times,  perhaps,  to  the  other  once.  Here  the  same  diffi- 
culty does  not  exist ;  for  the  uterus  is  now  unoccupied :  and  the 
only  matter  of  surprise  is  that  it  does  not  more  frequently  occur. 
Though  I  have  strenuously  contended  for  the  fact,  and  attempted 
an  explanation  of  it,  yet  I  am  well  persuaded  it  is  but  an  excep- 
tion to  the  rule,  and  not  an  ordinary  arrangement  of  nature. 

As  it  is  sometimes  of  consequence  to  determine  an  incipient 
pregnancy,  it  is  proper  to  notice  every  thing  relative  to  this  im- 
portant subject.  We  will,  therefore,  state  Mr.  Nauche's  obser- 
vations on  this  subject.  Some  years  since  this  gentleman  en- 
deavoured to  show,  that  the  urine  of  every  pregnant  woman  con- 
tained a  substance  that  he  denominated  Kiesteine,  which  sepa- 
rates from  it,  and  shows  itself  in  the  form  of  a  pellicle  on  its 
surface,  and  considers  it  as  a  valuable  diagnostic  sign  of  this 
state.  This  was  several  years  ago,  and  but  little  notice  was 
taken  of  it,  until  Mr.  Tanchou,  of  Paris,  recently  published  his 
observations  on  it  in  "  Lancette  Frangaise"  They  are  as  fol- 
low: 

"  He  examined  the  urine  of  twenty-five  pregnant  women,  and 
in  every  case  he  detected  the  presence  of  Kiesteine. — The  follow- 
ing is  the  description  he  gives  of  the  changes  which  the  urine 
during  pregnancy  exhibits,  and  of  the  characters  by  which  its 
peculiar  ingredients  may  be  recognised. 

"  The  urine  of  a  pregnant  woman,  collected  in  the  morning,  is 

'  Francis's  ed.  of  Penman,  p.  231. 


166  SUPPRESSION    OF    THE    MENSES. 

usually  of  a  pale  yellow  colour,  and  slightly  milky  in  appearance ; 
it  is  not  coagulable  by  heat,  or  by  any  of  the  tests  which  indicate 
the  presence  of  albumen.  Left  to  itself,  and  exposed  to  the  air 
after  the  first  day,  there  begins  'to  appear  suspended  in  it  a  cot- 
tony-looking cloud,  and,  at  the  same  time,  a  flocculent  whitish 
matter  is  deposited  at  the  bottom  of  the  fluid.  These  phenomena 
are  not  of  constant  occurrence,  and,  moreover,  healthy  urine 
sometimes  exhibits  analogous  phenomena.  From  the  second  to 
the  sixth  day  small  opaque  bodies  rise  from  the  bottom  to  the  top 
of  the  fluid ;  these  gradually  collect  together  so  as  to  form  a 
layer  which  covers  the  surface :  this  is  Kiesteine.  It  is  of  a 
whitish  or  opaline  colour,and  may  be  aptly  compared  to  the  layer 
of  greasy  matter  which  covers  the  surface  of  fat  broth,  when  it 
has  been  allowed  to  cool.  Examined  by  the  microscope,  it  exhi- 
bits the  appearance  of  a  gelatinous  mass,  which  has  no  deter- 
mined form.  Some  small  cubical  crystals  can  be  perceived  in  it, 
when  it  has  become  stale. 

"The  Kiesteine  continues  in  the  state  we  have  now  described 
for  three  or  four  days;  the  urine  then  becomes  muddy,  and  mi- 
nute opaque  bodies  detach  themselves  from  the  surface  to  settle 
at  the  bottom  of  the  vessel;  the  pellicle  thus  becomes  soon  de- 
stroyed. 

"The  characteristic  feature,  therefore,  of  the  urine  during 
pregnancy  consists  in  the  presence  of  Kiesteine.  It  deserves, 
however,  to  be  noticed,  that  the  urine  in  some  cases  of  extreme 
phthisis  pulmonalis,  and  also,  of  vcsical  catarrh,  will  be  found  to 
exhibit  on  its  surface  a  layer  of  stratum  which  is  not  unlike  to 
that  now  described  as  peculiar  to  the  state  of  pregnancy.  But 
with  proper  attention  we  may  easily  avoid  this  mistake.  The 
stratum,  in  the  cases  alluded  to,  does  not  appear  so  quickly  on 
the  surface  of  the  urine  as  the  Kiesteine ;  and  also,  instead  of 
disappearing,  as  it  is  found  to  do  in  a  few  days,  it  (the  former) 
goes  on  increasing  in  thickness,  and  ultimately  becomes  convert- 
ed into  a  mass  of  mouldiness. 

"  Of  twenty-five  cases,  in  which  Mr.  Tanchou  detected  the  pre- 
sence of  Kiesteine  in  the  urine,  seventeen  occurred  in  women  who 
were  pregnant  from  four  to  nine  months,  four  in  women  who  had 
quickened,  and  who  considered  themselves  as  labouring  under  dis- 
ease of  the  womb,  and  the  remaining  four  in  patients  who  had 
been  under  treatment  for  casual  complaints — one  for  sciatica  at 
the  Hotel  Dieu,  another  for  ascites  in  the  city,  a  third  for  an 
ulcer  in  the  neck  at  la  Pitie,  and  the  last  had  been  cauterized 
twice  a  week  for  a  pretended  disease  of  the  uterus. — In  none  of 
these  cases  had  the  existence  of  pregnancy  been  suspected,  al- 
though in  every  one  of  them  the  fact  was  soon  placed  beyond  a 
doubt."  Amer.  Journ.  Med.  Sciences,  for  Feb.,  1840,  p.  484. 

In  one  extraordinary  case,  which  fell  under  my  notice  in  1791, 


NAUSEA    AND    VOMITING.  167 

the  contrary  of  suppression  took  place  at  pregnancy:  a  woman 
applied  for  advice  for  a  long-standing  suppression  of  the  menses ; 
indeed,  she  never  had  menstruated  but  twice.  She  had  been 
married  a  number  of  months,  and  complained  of  a  good  deal  of 
derangement  of  stomach,  &c.  I  prescribed  some  rhubarb,  and 
steel  pills.  About  six  months  after  this,  she  again  called  to  say, 
"  that  the  medicine  had  brought  down  her  courses,  but  she  was 
more  unwell  than  before;  her  sickness  and  vomiting  had  in- 
creased, besides  swelling  very  much  in  her  belly."  I  saw  that 
this  was  pretty  much  distended,  and  immediately  examined  it,  as 
I  suspected  dropsy — but  from  the  feel  of  the  abdomen,  the  want 
of  fluctuation,  and  the  solidity  of  the  tumour,  I  began  to  think  it 
might  be  pregnancy,  and  told  the  woman  my  opinion.  She  now 
became  anxious  to  understand  her  situation  exactly,  and  sub- 
mitted, for  this  purpose,  to  an  examination  per  vaginam ;  this 
proved  her  to  be  six  months  advanced  in  pregnancy :  after  this 
time,  she  had  the  regular  returns  of  her  catamenial  period  until 
the  full  time  had  expired.  During  the  period  of  suckling,  she 
was  free  from  the  discharge:  she  was  a  nurse  for  more  than 
twelve  months ;  she  weaned  her  child,  and,  shortly  after,  she  was 
again  surprised  by  an  eruption  of  the  menses,  which,  as  on  the 
former  occasion,  proved  to  be  a  sign  of  pregnancy.  Whether  this 
peculiarity  pursued  her  still  farther,  I  cannot  say;  as  she  removed 
from  the  neighbourhood  soon  after  the  birth  of  her  second  child. 
Whether  there  was  a  periodical  discharge  of  a  colourless  fluid 
in  this  case,  as  a  compensation  for  the  regular  menses,  I  am  un- 
able to  say,  as  I  did  not  examine  the  woman  on  this  point,  not 
having,  at  that  time,  the  same  interest  as  now,  in  such  minute  in- 
quiry. I  merely  state  the  main  facts,  though  they  bid  defiance 
to  calculation,  and  almost  to  example ;  Deventer1  being  the  only 
author,  so  far  as  I  know,  who  has  furnished  a  similar  example. 


SECT.  II. — 2.  Nausea  and  Vomiting. 

Nausea  and  vomiting,  though  a  very  usual  concomitant,  is 
very  far  from  being  a  certain  sign  of  pregnancy:  it  occurs  some- 
times where  the  menses  have  been  delayed  by  other  causes:  it 
may,  however,  be  considered  as  adding  to  the  general  testimony 
in  proof  of  this  condition.  Should  the  child  die  while  in  utero, 
the  vomiting,  for  the  most  part,  ceases  immediately. 

'  Chapter  xv.  p.  65. 


.    .    *      %  '.  * 

168  AREOL.fi. 


SECT.  III. — 3.  Enlargement  of  the  Mammse. 

'-•''•   '  •    •'       .  -'iC't    *  .'  f>U  M.t1<i  .;/« '»<jffi 

Enlargement  of  the  mammae  is  a  very  common  attendant  upon 
genuine  pregnancy,  though  it  is  not  uniformly  so.  I  have' known 
a  number  ^f  cases  where  they  did  not  swell  even  at  the  latter 
periods  of  gestation ;  nor  was  it  until  after  delivery,  that  they 
gave  evidence  of  capacity  to  perform  their  ordinary  functions : 
on  the  other  hand,  I  have  known  them  to  enlarge  considerably, 
where  the  menses  were  interrupted  from  other  causes  than  preg- 
nancy.1 

SECT.  IV. — 4.  Areolx. 

The  areolae,  which  are  sometimes  formed  round  the  nipples, 
must  be  considered  as  equivocal  in  any  but  a  first  pregnancy : 
in  this  case  did  areolae  form,  I  should  place  great  dependence 
upon  them ;  for,  so  far,  I  have  not  been  deceived.  They  do  not, 
however,  always  present  themselves ;  and  may  not  be  easily  de- 
tected, even  when  formed,  in  very  dark-skinned  women :  there  is 
always,  I  believe,  an  enlargement  of  the  little  sebaceous  glands 
which  surround  the  nipples,  when  areolse  encircle  them :  and 
they,  as  far  as  my  observations  go,  serve  to  strengthen  the  sus- 
picion of  pregnancy.  So  far  as  I  recollect,  this  blush  is  not 
mimicked  by  obstructed  catamenia,  or  from  any  other  cause  than 
pregnancy.  It  is  possible  that  they  may  attend  a  false  concep- 
tion or  mole ;  but  of  this  I  have  no  experience.  In  a  second  or 
other  pregnancies,  I  do  not  place  the  same  reliance  upon  this 
sign ;  as  a  trifling  irritation,  or  other  causes,  I  believe,  may  pro- 
duce them ;  or  they  may,  as  I  have  often  noticed,  be  absent  alto- 
gether. The  marks  I  have  been  speaking  of,  must  not  be  con- 
founded with  the  permanent  stain  left  around  the  nipple  after  a 
woman  has  suckled  a  child ;  and  great  care  should  be  taken  to 
conduct  this  inquiry  in  such  a  manner  as  to  give  no  false  im- 
pressions. Dr.  Ingleby  considers  the  areolse  as  a  proof  of  preg- 
nancy. 

When  the  nipples  are  to  be  examined,  the  woman  should  open 
her  bosom  so  as  to  expose  the  whole  breast :  she  must  not  be  suf- 
fered to  draw  it  above  the  margin  of  her  clothes  by  placing  her 
hand  beneath  it. — In  doing  this,  the  nipple  oftentimes  is  irritated 
by  the  pressure  of  the  fingers,  which  gives  a  new  character  to 
the  appearances.  I  have,  in  a  number  of  instances,  detected 
pregnancy  by  this  examination,  where  the  patients  insisted  their 

1  We  have  met  with  this  symptom  in  a  number  of  cases:  a  swelling  and  tender- 
ness takes  place  in  simple  obstruction,  and  we  have  known  it  accompany  the 
menstrual  discharge.  In  cases  of  the  latter  kind  it  appears  to  be  habitual. 


FORMATION    OP   MILK.  169 

irregularity  proceeded  from  cold  or  other  causes.  It  must,  how- 
ever, be  remembered,  that  the  absence  of  these  areolse  does  not 
prove  the  woman  unimpregnated. 

In  one  case  I  detected  pregnancy  when  it  was  not  suspected: 
a  lady  "who  had  been  several  years  married  without  becoming 
pregnant,  sent  for  me  to  examine  her  mamma,  which  she  said, 
had  a  tumour  in  it.  As  soon  as  I  saw  the  breast  my  attention 
was  challenged  to  a  more  particular  examination.  The  areolse 
were  so  extensive  and  deep  toned,  and  the  little  glands  were  so 
enlarged,  and  prominent,  that  it  immediately  struck  me,  that 
besides  the  small  tumour,  (which  was  nothing  more  than  but 
one  of  the  glands  of  her  breast,  swelled  or  enlarged,)  she  was 
pregnant;  I  mentioned  my  suspicion — she  laughed  at  me,  as  did 
the  husband; — but  time  proved  I  was  right,  much  to  their  joy. 


SECT.  V. — 5.  Formation  of  Milk. 

The  formation  of  milk,  in  the  mammae  is  coeval,  in  some  preg- 
nant women,  with  their  swelling;  while  in  others  it  is  not  formed 
until  after  delivery.  When  this  secretion  takes  place,  it  is  looked 
upon  by  the  vulgar  as  a  certain  sign  of  pregnancy ;  but  I  have 
oftentimes  known  this  fluid,  (or  at  least  a  fluid  bearing  all  the 
marks  of  the  first  formed  milk,)  plentifully  secreted  without  preg- 
nancy, merely  by  the  interruption  of  the  menses.  It  has  been 
produced  in  women  past  the  period  of  child-bearing,  and  even, 
it  is  said,  in  men1  by  the  repeated  application  of  a  child  to  the 
nipple.  It  has  also  been  produced  in  a  girl  of  eight  years  old, 
as  we  are  informed  by  Baudelocque.  (See  his  very  interesting 
case.  Vol.  I.  page  219.) 

I  once  knew  a  considerable  quantity  of  milk  form  in  the  breasts 
of  a  lady,  who,  though  she  had  been  married  a  number  of  years, 
had  never  been  pregnant ;  but  who  at  this  time  had  been  two 
years  separated  from  her  husband.  She  mentioned  the  fact  of 
her  having  milk  to  a  female  friend,  who,  from  an  impression  that 
it  augured  pregnancy,  told  it  to  another  friend,  as  a  great  secret ; 
who  in  her  turn  mentioned  it  to  another  friend,  and  thus,  after 
having  enlisted  fifteen  or  twenty  to  help  them  keep  the  secret, 
it  got  to  the  ears  of  the  lady's  brother.  His  surprise  was  only 

1  The  following  case  is  in  proof  of  this  assertion:  it  is  communicated  by  Mr. 
Heber  Chase,  of  New  Hampshire. 

A  Mr.  James  Hildrelh,  of  Hopkinton,New  Hampshire,  was,  about  three  years 
since,  (Dec.  9th,  1834,)  from  the  abundant  secretion  of  milk  in  his  right  breast, 
enabled,  by  pressing  it  with  his  fingers,  to  project  milk  from  the  nipple  two  or 
three  feet.  Mr.  Chase  declares  he  has  seen  him  do  so  often  at  the  young  people 
around  him.  He  was  a  blacksmith  by  trade,  and  a  muscular,  robust  man,  some- 
what dissipated,  but  not  so  much  so  as  to  interfere  with  his  business,  lie  was 
about  thirty  years  of  age,  and  the  father  of  several  children. 


*    4 

170        ENLARGEMENT  OF  THE  ABDOMEN. 

equalled  by  his  rage ;  and,  in  a  paroxysm,  he  accused  his  sister, 
in  the  most  violent  and  indelicate  terms,  of  incontinency,  and 
menaced  her  with  the  most  direful  vengeance. 

The  lady,  conscious  of  her  innocence,  desired  that  I  should  he 
sent  for,  forthwith;  and  insisted  her  brother  should  not  leave 
the  room  until  I  arrived :  some  time  elapsed  before  this  could 
be  accomplished,  as  we  were  several  miles  from  each  other, 
during  the  yellow  fever  of  1798.  During  the  whole  of  this  time 
she  bore  his  threats  and  revilings  with  the  utmost  exemplary 
patience  and  silence.  I  at  length  arrived ;  and,  in  the  presence 
of  the  brother  and  a  female  friend,  she  informed  me  of  what  I 
have  just  stated;  and  said  her  object  in  sending  for  me  was,  to 
submit  to  such  an  examination  as  I  might  judge  proper,  to  de- 
termine whether  she  were  pregnant  or  not.  She  would  not  per- 
mit her  brother  to  leave  the  chamber ;  and  I  conducted  the  ex- 
amination without  his  withdrawing.  This  thing  turned  out  as 
I  had  anticipated,  from  the  history  given  at  the  moment,  of  her 
previous  health.  I  pronounced  her  not  pregnant ;  and  she  died 
in  about  eight  months  after,  of  phthisis  pulmonalis,  in  which  dis- 
ease the  destruction  of  the  catamenia  is  not  an  unfrequent  occur- 
rence. 


SECT.  VI. — 6.  Enlargement  of  the.  Abdomen. 

The  enlargement  of  the  abdomen,  perhaps,  is  one  of  the  most 
equivocal  of  the  enumerated  signs,  since  it  may  take  place  from 
so  many  other  causes  as,  1st.  Dropsical  affections  of  ^either  the 
abdomen,  uterus,  or  ovaria.1  2d.  A  chronic  disease  of  the  ova- 
ria,  or  uterus  itself.  3d.  A  retention  of  the  menses,  from  some 
accidental  cause  preventing  their  flow.3  4th.  Enlargement  of  al- 
most any  of  the  abdominal  viscera.  5th.  The  simple  obstruction 
of  the  catamenia.  For  these  reasons,  but  little  reliance  can  be 
placed  upon  this  circumstance  alone,  or  even  when  combined 
with  several  others.  For  I  have  had  the  pleasure,  in  several 
instances,  of  doing  away  any  injurious  and  cruel  suspicion,  to 
which  this  enlargement  had  given  rise.  Within  a  short  time,  I 

1  Dr.  Blundell  relates  the  following  interesting  case,  which  should  be  kept  in 
recollection,  as  a  beacon  to  shun  a  similar  error. 

Dr.  Haighton  was  sent  for  in  consultation  with  a  distinguished  London  surgeon, 
to  a  case  supposed  to  be  ascites,  for  which  the  patient  was  to  be  tapped  the  next 
day.  Dr.  Haighton  suggested  that  this  swelling  might  be  a  dropsy  of  the  uterus, 
but  no  particular  examination  w«s  made  to  ascertain  this.  During  the  night,  the 
sac  containing  this  fluid  gave  way,  a  "  flood  of  fluid  was  discharged,  and  the  ab- 
domen collapsed  rapidly;  a  foetus  not  larger  than  the  first  joint  of  the  finger 
escaped,  the  woman  escaped  the  paracentesis,  and  did  well." — Princip.  and  Prac. 
of  Obstet.  p.  78. 

*  See  Miss  F's.  case,  in  Essays  on  various  Subjects  connected  with  Midwifery, 
page  337,  by  the  author. 


INCREASED    SIZE   OF    THE   UTERUS.  171 

relieved  an  anxious  and  tender  mother  from  an  almost  heart- 
breaking apprehension  for  the  condition  of  an  only,  and  beauti- 
ful  daughter,  on  -whom  suspicion  had  fallen,  though  not  quite 
fifteen  years  of  age.  This  case,  it  must  be  confessed,  combined 
several  circumstances  which  rendered  it  one  of  great  doubt; 
and  without  having  had  recourse  to  the  most  careful  and  mi- 
nute examination,  might  readily  have  embarrassed  a  young 
practitioner. 

This  young  lady's  case  was  submitted  to  a  medical  gentleman, 
who,  from  its  history  and  the  feel  of  the  abdomen,  pronounced  it 
to  be  a  case  of  pregnancy;  and  advised  the  sorrow-stricken  mo- 
ther to  send  her  daughter  immediately  to  the  country,  as  the 
best  mode  of  concealing  her  shame.  Not  willing  to  yield  to  the 
opinion  of  her  physician,  (a  young  man,)  and  moved  by  the 
positive  denials  of  her  agonized  child,  the  mother  consulted  me. 
The  history  of  the  case  was  thus  briefly  given  by  the  mother: 
"  Her  daughter  commenced,  between  twelve  and  thirteen,  to  men- 
struate, and  continued  to  do  so,  regularly,  until  late  last  fall;1 
at  which  time  she  had  a  very  smart  attack  of  the  prevailing 
epidemic ;  of  this  she  was,  however,  relieved  by  the  usual  reme- 
dies ;  but  since  which  time  she  had  never  menstruated;  she 
gradually  swelled  in  the  belly;  her  stomach  was  much  affected, 
especially  in  the  morning ;  and  the  breasts  were  a  little  enlarged." 

I  examined  the  mammae,  and  found  them  a  little  tumid,  but 
without  areolse ;  the  abdomen  was  much  enlarged,  tense,  and 
hard,  in  consequence  of  a  large  tumour  which  was  confined  to 
the  left  side  of  this  cavity,  and  which  could  be  easily  traced 
throughout  its  right  and  inferior  margin,  and  proved,  (at  least  in 
my  opinion,)  to  be  an  enlarged  spleen ;  no  tumour  was  found  in 
the  pubic  region ;  consequently,  the  uterus  was  not  found  en- 
larged; the  navel  was  sunk;  and  upon  an  attempt  to  pass  the 
finger  into  the  vagina,  I  found  so  much  evidence  of  her  conti- 
nency,  that  I  did  not  persevere,  being  perfectly  satisfied,  from 
the  condition  of  the  parts,  that  she  was  a  virgin.  I  unhesita- 
tingly, and  with  no  common  degree  of  pleasure,  declared  the 
poor  child  to  be  free  from  the  charge  so  heedlessly  and  cruelly 
preferred  against  her. 

SECT.  VII. — 7.  Increased  Size  of  the  Uterus. 

An  increased  size  of  the  uterus,  especially  in  young  women, 
either  married  or  single,  will  necessarily  create  a  suspicion  that 
it  may  arise  from  pregnancy;  particularly  if  its  surface,  as  dis- 
tinguished through  the  abdominal  parietes  be  uniformly  round, 
smooth,  and  elastic;  and  if  there  be  combined  with  these  marks, 

1    1832. 


172  SPITTING    OF   FROTHY    SALIVA. 

several  of  the  rational  signs  of  pregnancy — but  it  is  far  from 
being  infallible.  This  distention  of  the  uterus  may  arise,  1st, 
from  a  dropsical  state  of  the  uterus;  2dly,  from  diseases  within 
its  cavity,  as  tumours,  or  excrescences ;  3dly,  from  moles,  or 
false  conceptions,  or  hydatids ;  4thly,  from  a  retention  of  the 
menstruous  discharge  from  the  occlusion  of  the  os  tincae,  &c. 
The  case  referred  to,  of  Miss  F.,  is  strictly  in  point ;  and  was 
one,  among  others,  where  injurious  surmises  were,  for  a  long  time, 
most  cruelly  entertained.1 

SECT.  VIII. — 8.  Pouting  out  of  the  Navel. 

Pouting  out  of  the  navel,  if  it  takes  place,  only  proves  that  there 
is  something  behind,  which  makes  it  protrude  ;  but  it  by  no  means 
follows,  that  it  is  the  uterus  distended  by  pregnancy :  I  believe  it 
invariably  takes  place  in  pregnancy  after  the  sixth  month,  or 
sometimes  even  earlier;  and  I  think  the  following  conclusions 
may  pretty  safely  be  drawn  from  this  condition  of  the  navel :  1st, 
If  the  woman  be  pregnant,  it  will,  by  its  projection,  indicate  the 
advancement  to  be  at  least  six  months ;  yet  the  woman  may  be 
advanced  to  the  fifth  or  a  little  beyond  it.  without  this  part  under- 
going a  change ;  2dly,  If  this  part  protrude,  it  will  by  no  means 
follow,  without  the  concurrence  of  other  signs,  that  the  woman  is 
pregnant ;  for  this  may  happen  from  any  cause,  independently  of 
pregnancy,  that  is  capable  of  distending  the  uterus  to  a  size  equal 
to  the  sixth  or  seventh  month;  as  in  ascites,  when  the  abdomen 
is  much  stretched;  from  sanguineous  sarcoma;  from  hydatids; 
chronic  enlargements  of  the  liver,  and,  perhaps,  of  some  other 
of  the  abdominal  viscera.  When  this  part  does  not  protrude,  we 
are  not  to  conclude  that  the  woman  is  not  pregnant ;  as  it  re- 
quires the  presence  of  the  uterus  behind  it,  to  make  it  appear ; 
and,  therefore,  whatever  is  capable  of  preventing  its  presence 
immediately  behind  the  navel,  as  insufficient  development,  or  its 
sinking  unusually  low  in  the  pelvis  from  the  extraordinary  size 
of  this  cavity,  is  capable  of  interrupting  this  protrusion. 

SECT.  IX. — 9.  Spitting  of  Frothy  Saliva. 
Spitting  of  very  white  frothy  mucus  is  by  no  means  a  constant 

1  Since  this  period,  I  have  met  with  a  case  very  similar  to  that  of  Miss  F.'s  in 
a  married  lady,  but  who  had  never  been  pregnant.  This  case,  naturally  enough, 
was  looked  upon  as  one  of  pregnancy,  as  there  was  no  apparent  incapacity — all  the 
rational  signs  of  this  condition  were  present;  and  it  was  supposed  that  the  pa- 
tient was  in  her  seventh  month  of  gestation.  On  the  fifth  of  May,  1830,  she  was 
suddenly  surprised  by  a  large  flow  of  a  fluid  resembling  blood,  but  in  which  there 
was  neither  coagula,  foetus,  nor  placenta.  The  abdominal  intumescence  quickly 
subsided,  and  the  patient  was  very  soon  relieved  of  all  the  symptoms  which  re 
sembled  pregnancy. 


SALIVATION.  173 

attendant  upon  pregnancy ;  but  when  it  does  occur,  it  very  cer- 
tainly points  out  this  condition.  This  saliva  is  very  tenacious, 
and  very  difficult  to  deliver  from  the  mouth ;  it  is  extremely  white, 
and  a  little  frothy;  and,  when  discharged  upon  the  floor,  assumes 
a  round  shape,  and  about  the  size  of  a  shilling  piece :  hence  the 
expression,  that  the  person  is  "  spitting  English  shillings,  or 
cotton;"  and,  so  far  as  I  have  remarked,  it  is  almost  a  certain 
sign  of  pregnancy. 

SECT.  X. — 10.  Salivation. 

Salivation,  like  the  sign  just  mentioned,  is  not  a  constant  at- 
tendant upon  pregnancy,  except  in  a  very  moderate  degree;  in- 
deed it  is  not  very  rare,  though  it  seldom  exists  in  excess :  but, 
when  it  does  happen,  it  very  decidedly  points  out  this  condition. 
— I  do  not  remember  to  have  observed  this  symptom  from  any 
other  state  of  the  uterus.1 

From  what  has  been  said,  it  appears  that  the  rational  signs, 
(as  they  have  been  termed,)  of  pregnancy,  may  exist  in  stronger 
or  weaker  combination,  without  proving  it  unequivocally;  though 
they  may  leave  little  or  no  room  for  reasonable  doubt  of  its  ex- 
istence. There  is,  then,  but  one  mark,  by  which  pregnancy  can 
be  absolutely  determined — and  that  is,  the  movements  of  the 
foetus  itself  within  the  uterus.  In  judging  of  this  we  are  not  to 
rely  upon  the  ipse  dixit  of  the  woman,  as  she  may  be  deceived, 
or  have  motives  to  mislead;  upon  this  point,  therefore,  we  must 
determine  for  ourselves. 

Upon  this  point  Dr.  Blundell  furnishes  us  with  the  following 
curious  facts :  "  I  know  an  instance  of  a  lady  possessing  more 
than  average  intelligence,  the  mother  of  twelve  children,  who  was 
led  by  certain  abdominal  movements  into  an  erroneous  persuasion 
that  she  was  again  pregnant ;  for  spasms  of  the  abdominal  mus- 
cles, and  flutters  of  the  bowels,  may  now  and  then  be  mistaken 
for  the  movements  of  a  child.  It  ought,  moreover,  to  be  known, 
that  some  women  possess  the  power  of  similating  the  foetal  move- 
ments, by  the  action  of  the  abdominal  muscles,  so  exactly,  that 
even  an  experienced  accoucheur  might  be  deceived.  A  female 
who  possessed  considerable  skill  of  this  kind,  formerly  exhibited 
her  talents  in  this  town  (London,)  for  hire ;  she  was  visited  by 

1  Since  writing  the  above,  I  have  met  with  two  instances  of  salivation  in  fe- 
males, which  was  not  produced  by  pregnancy,  or  any  other  known  cause.  One  was 
extremely  profuse,and  lasted  full  three  weeks,  in  defiance  of  all  applications.  The 
fluid  was  nearly  tasteless,  and  was  without  the  slightest  odour :  it  ceased  gradually, 
and  I  may  say  spontaneously;  for  no  remedy  that  was  used  appeared  to  make  the 
slightest  impression  upon  the  discharge.  This  affection  seemed  to  arise  from  some 
condition  of  the  stomach,  as  much  nausea  attended.  The  other  was  less  profuse, 
and  more  obedient  to  remedies — a  strong  infusion  of  cinnamon  appeared  to  afford 
complete  relief,  though  it  was  altogether  unavailing  in  the  other  instance. 


174  OF    QUICKENING. 

Lowder,  Mackenzie,  and  some  other  celebrated  accoucheurs  of 
the  day,  and  after  satisfying  themselves  that  the  uterus  was  not 
enlarged,  they  made  the  usual  examination  of  the  abdomen,  when 
they  all  agreed  that  the  movement  was  so  exactly  analogous  to 
that  of  the  foetus,  that  no  distinction  could  be  clearly  made,  adding, 
if  there  had  been  no  internal  examination  made,  they  should, 
judging  from  this  only,  have  satisfied  themselves  that  the  woman 
was  with  child." 

To  do  this  it  is  necessary  to  place  the  hand  upon  the  bare  ab- 
domen, and  wait  for  the  motion  of  the  child ;  or  we  may  endeavour 
*  to  provoke  it,  by  having  the  hand  either  hot  or  cold,  according 
to  the  season,  as  recommended  by  Morgagni;  and  as  has  been 
often  practised  successfully  by  myself.  Should  the  weather  be 
hot,  we  should  have  the  temperature  of  the  hand  reduced  by  cold 
water,  or  ice ;  or,  if  the  weather  be  cold,  have  the  temperature 
raised,  by  placing  the  hand  in  warm  water  for  a  short  time.  By 
these  means  we  rarely  fail  to  excite  the  foetus  to  action ;  and  we 
may  succeed  in  having  it  even  pretty  frequently  repeated,  by 
repeating  the  same  means.  Of  this  fact  I  am  perfectly  certain : 
but,  to  account  for  it,  is  beyond  my  ingenuity.  By  touching  per 
vaginam,  we  may  ascertain,  that  the  uterus  contains  a  solid  body 
within  it:  but  we  cannot,  by  this  method,  determine  whether  it 
be  a  living  being,  or  an  imperfectly  organized  mass. 

Will  the  absence  of  all  motion  within  the  uterus  determine  the 
woman  not  to  be  pregnant,  when  a  sufficient  number  of  the 
rational  signs  combine  to  render  it  more  than  probable  that  she 
is  ?  I  must  answer  this  question  in  the  negative ;  as  instances 
have  occurred  to  others,1  and  one  to  myself,  where  the  motions 
of  the  child  were  never  perceived,  during  the  whole  period  of 
utero-gestation.  In  such  cases,  an  examination,  per  vaginam, 
will  aid  much;  especially  at  the  latter  period  of  pregnancy — 
the  state  of  development  of  the  uterus ;  the  feel  of  the  substance 
contained  in  it ;  the  condition  of  the  os  tincae ;  the  height  of  the 
fundus,  &c.,  will,  when  taken  into  consideration,  and  found  per- 
fectly to  correspond  with  the  woman's  history  of  herself,  prevent 
any  serious  error  in  our  estimate. 

SECT.  XI. — 11.     Of  Quickening. 

By  quickening  we  are  to  understand  the  first  perception  the 
woman  has  of  the  child's  muscular  action.  It  is  presumable,  that 
it  has  in  a  very  feeble  manner  exerted  itself  very  often  before  it 
is  or  can  be  noticed  by  the  mother;  and  the  moment  at  which 
this  action  becomes  obvious  to  her,  must  be  at  different  periods 
of  pregnancy,  in  different  women,  owing  to  the  greater  or  less 

1  Levret,  as  quoted  by  Baudelocque,  Vol.  I.  p.  240. 


OF   QUICKENING.  175 

strength  of  the  foetus;  the  quantity  of  the  liquor  aranii;  and  the 
sensibility  of  the  uterus  itself.  I  once  knew  a  lady  of  great  ner- 
vous sensibility,  who  constantly  perceived  the  motions  of  her 
children  at  twelve  weeks  ;  others  are  longer,  and  may  be  said  to 
be  at  every  period  between  the  twelfth  week  and  seventh  month 
— the  medium  period  is  the  most  common ;  and  when  I  declare 
the  most  usual  to  be  at  the  fourth  month,  I  am,  perhaps,  as  near 
the  truth  as  can  well  be  ascertained.1 

An  anonymous  writer  in  the  Medical  and  Physical  Journal  for 
June,  1812,  under  the  name  of  "Medicus,"  has  puzzled  himself, 
besides  appearing  willing  to  puzzle  every  body  else,  by  a  learned 
attempt  to  explain  the  cause  of  quickening  by  physical  and  meta- 
physical reasoning  upon  the  subject.  He  evidently  confounds 
two  circumstances  totally  distinct,  (if  one  of  them  really  has  an 
existence,)  in  their  natures,  under  one  general  term ;  namely,  the 
first  perceptible  motion  of  the  foetus  is  confounded  with  a  sup- 
posed sudden  change  in  the  uterus,  at  the  period  the  fundus 
usually  appears  above  the  superior  strait.  The  disposition  to 
syncope,  which  is  sometimes  f«lt  by  women  at  about  the  fourth 
month,  he  calls  quickening;  and  declares  it  to  be  owing  to  the 
sudden  escape  of  the  uterus  from  restraint  to  liberty,  by  mount- 
ing above  the  brim  of  the  pelvis,  and  there  enjoying  greater  free- 
dom and  repose.  He  will  not  admit  that  any  motion  of  the  child 
constitutes  quickening ;  but  that  it  essentially  depends  upon  the 
change  of  position  of  the  uterus  itself.  He  rejects  the  common 
and  "ancient"  explanation  of  quickening,  for  the  following  rea- 
sons : — 

1st,  "  The  sensation  of  quickening,  (by  which  he  does  not 
wish  to  be  understood  to  mean  any  muscular  action  of  the  foetus,) 
is  not  constant  and  universal ;  some  women  never  experience  it, 
others  with  some  of  their  children  only. 

2d.  It  has  a  distinct  character  from  any  subsequent  motion  of 
the  child ;  no  woman  ever  admits  that  it  resembles,  in  the  slightest 
degree,  the  struggles  of  the  foetus. 

3d.  This  sensation  is  never  repeated  in  the  same  pregnancy, 
which  must  happen  if  it  arose  from  the  motion  of  the  child. 

4th.  It  is  totally  incomprehensible  that  any  motion  of  which 
the  fcetus  is  capable,  in  the  fourth  month,  should  communicate 
such  a  sensation  to  the  mother,  as  to  produce  deliquium  animi."2 

The  whole  of  these  arguments  go  to  declare,  that  when  the 
uterus  suddenly  overcomes  any  restraint  to  its  passage  out  of  the 

1  See  Chapter  on  the  Term  of  Utero-gestation,  in  System  of  Midwifery,  by  the 
author. 

'We  were  much  surprised  to  find  this  notion  of  "quickening,"  adopted  by  Mr. 
Morley,  a  late  writer,  "upon  the  symptoms  of  pregnancy,  &c."  We  think  it 
probable,  that  this  gentleman  will  be  induced  to  call  things  by  their  right  names, 
when  he  has  more  experience  to  aid  him. 


176  OF   QUICKENING. 

brim  of  the  pelvis,  the  woman  is  wont  to  feel  faint;  and  he  con- 
founds this  feeling,  if  it  exist,  with  the  sensation  which  all  wo- 
men, (as  a  general  rule,)  experience,  after  the  foetus  has  acquired 
sufficient  strength  to  make  itself  felt;  and  which  increases  in 
force,  and  is  multiplied  in  frequency,  as  gestation  advances ;  or, 
in  other  words,  he  calls  the  sensation  created  by  the  uterus  sud- 
denly rising  above  the  superior  strait,  quickening;  but  declares 
it  to  be  distinct  from  the  motions  of  the  foetus.  In  this  I  most 
fully  agree;  as  I  do  not  believe  that  the  uterus  is  ever  so  sud- 
denly elevated  into  the  abdomen,  as  to  produce  the  sensation  of 
faintness.  I  am,  by  no  means,  convinced  of  this  sudden  eleva- 
tion of  the  uterus,  by  the  inquiries  1  have  made  of  women,  (who, 
one  would  suppose,  were  the  best  judges  upon  this  subject.)  My 
inquiries,  however,  have  resulted  in  the  establishment  of  the 
following  facts : — 1st.  That  all  women  experience,  some  sooner, 
others  later,  the  sensation  which  they  term  quickening;  2d.  In 
some,  this  feeling  is  accompanied  by  a  disposition  to  faintness,  or 
rather  of  sinking,  as  they  express  it ;  and  this  is  experienced,  in 
some  few  instances,  whenever  the  motion  of  the  child  is  repeated, 
until  after  the  fifth  month;  3d.  That  those  who  "quicken"  very 
early,  are  most  obnoxious  to  this  enfeebling  sensation;  4th. 
That,  when  the  feeling  of  faintness  comes  on,  they  are  certain 
it  is  always  produced  by  the  motion  of  the  child  itself ;  5th. 
That  none  have  ever  been  sensible  of  any  disposition  to  deliquium, 
but  from  the  stirrings  of  the  foetus. 

These  facts  are  conclusive,  that  the  sensation  in  question  is 
the  result  of  the  muscular  agitations  of  the  child ;  and  that  the 
explanation  of  "Medicus,"  is  at  variance  with  this  opinion;  con- 
sequently, not  calculated  to  explain  the  phenomenon.  Besides, 
the  circumstance  mentioned  by  "Medicus,"  of  the  sudden  erup- 
tion of  the  uterus  from  the  pelvic  cavity,  has  no  existence;  «tnd 
even  if  it  were  true,  I  do  not  see  why  this  change  of  position  is 
to  be  confounded  with  the  absolute  stirrings  of  the  foetus.  If  he 
can  make  out  his  position,  that  the  uterus  suddenly  surmounts 
certain  difficulties  in  its  attempt  to  rise  higher  in  the  pelvis,  and 
that  this  is  accompanied  by  deliquium  animi,  it  is  well ;  but  for 
the  sake  of  precision,  and  of  logic,  do  not  let  him  confound  it 
with  quickening. 

Besides,  there  is  a  want  of  ingenuousness  in  the  statement  of 
facts  by  "Medicus;"  for  we  are  yet  to  discover,  that  any  one 
has  explained  the  term  "quickening,"  by  saying  it  was  owing 
"to  life  being  suddenly  imparted  to  the  embryo."  This  would 
in  itself  be  absurd,  and  contrary  to  all  belief  upon  the  subject; 
for  I  do  not  hazard  much  when  I  say  that  there  is  no  one  at 
present,  nor  perhaps  ever  has  been,  who  supposed  that  the  em- 
bryo did  not  possess  life  from  the  instant  it  obeyed  the  stimulus 
of  the  male  semen  for  development;  and  for  this  plain  and  sim- 


OF    QUICKENING.  177 

pie  reason,  that  if  it  were  not  alive,  it  must  be  dead;  and  if  dead, 
it  must  be  cast  off  by  the  womb,  as  an  extraneous  substance. 
There  must  be  a  period  when  the  embryo  is  not  sufficiently  de- 
veloped to  move ;  another  when  this  can  be  but  feebly  and  im- 
perfectly performed;  and  another,  when  it  can  move  with  suffi- 
cient force  to  give  evidence  of  this  increase  of  power ;  and  this 
moment  is  instantly  recognised  by  the  mother,  who  then  says, 
she  has  "quickened;"  and  that  this  novel  sensation  should  be 
accompanied  by  novel  effects,  and  even  sometimes  by  syncope, 
is  no  way  surprising.  The  older  writers  merely  wished  to  be 
understood,  by  the  term  quickening,  that  moment  at  which  the 
embryo  gave  the  first  physical  proof  of  life ;  and  not  the  moment 
it  received  it. 

That  an  abatement  of  the  severity  of  the  symptoms  of  preg- 
nancy takes  place  about  the  period  of  "quickening  "  I  am  well 
convinced;  and  that  this  takes  place  with  greater  certainty,  when 
the  uterus  can  repose  itself  upon  the  anterior  portion  of  the  pel- 
vis; yet  I  am  unwilling  to  admit,  that  this  change  is  owing  to 
the  sudden  rise  of  the  uterus  above  the  brim  of  the  pelvis,  as  is 
declared  by  "Medicus:"  1st.  Because,  I  do  not  know  that  this 
has  ever  taken  place  as  a  natural  arrangement ;  and  2d.  Because 
if  it  did,  it  might  create  the  unpleasant  sensations  agreed  upon 
by  "Medicus." 

To  me  the  amelioration  of  symptoms  at  this  period  appears  to 
depend  upon  two  circumstances  mainly;  1st.  Upon  the  uterus 
being  enabled  to  repose  upon  the  symphysis  pubis  and  its  neigh- 
bourhood; therefore,  no  longer  liable  to  be  depressed  in  the  ca- 
vity of  the  pelvis,  by  the  often  repeated  impulses  of  the  abdomi- 
nal viscera.  2d.  To  the  sensibility  and  irritability  of  the  uterus 
being  diminished  by  the  frequent  repetitions  of  the  child's  mo- 
tions; in  this  obeying  the  law,  which  seems  to  govern  every 
other  portion  of  the  system  as  regards  the  operation  of  stimuli, 
by  becoming  less  and  less  sensible  to  them,  in  proportion  to  the 
frequency  of  their  application ;  hence,  parts  pretty  uniformly 
sympathizing  with  the  uterus  when  impregnated,  will  cease  to 
do  so,  or  will  do  so  in  a  more  moderate  degree,  as  that  viscus 
shall  be  itself  less  affected. 

From  what  has  been  said,  it  will  be  evident,  that  much  diffi- 
culty exists  in  determining  that  condition  of  the  female  called 
"  pregnancy."  We  have  endeavoured  to  show  that  the  "rational 
signs"  of  this  state  are  particularly  liable  to  error;  and,  there- 
fore, that  where  it  becomes  highly  important  to  determine  this, 
point  they  are  not  to  be  absolutely  relied  upon,  however  strongly 
the}r  may  be  marked,  or  however  numerously  they  may  be  com- 
bined. In  the  more  early  advancement  of  this  process,  even  to 
the  fourth  month,  the  difficulty  of  arriving  at  entire  certainty  is 
acknowledged  by  all  who  have  any  experience  upon  this  subject; 
12 


178  OP    QUICKENING. 

and,  that  the  one  so  much  relied  upon  by  Baudelocque  and  many 
other  experienced  accoucheurs,  namely,  the  motion  of  the  child, 
has  lately  been  looked  upon  as  doubtful  by  Mr.  Morley.  He 
says,  it  is  possible  for  wind  or  other  intestinal  motion  to  be  mis- 
taken for  the  motions  of  the  child.1  Now,  this  we  declare  to  be 
impossible  to  the  experienced  accoucheur,  who  has  been  attentive 
to  this  part  of  the  practice ;  though  we  acknowledge  it  to  be 
every  way  probable,  to  the  inattentive  and  inexperienced  prac- 
titioner. Mr.  Morley  appears  to  have  fallen  into  this  mistake 
from  the  opinion  he  has  so  inconsiderately  adopted,  of  the  cause, 
or  rather  the  nature,  of  "quickening;"  namely,  the  ascent  of  the 
uterus  through  the  upper  strait  of  the  pelvis,  instead  of  the  mo- 
tion of  the  child,  by  the  exercise  of  its  muscular  powers  within 
the  uterus,  as  has  already  been  noticed  above.  The  accoucheur 
who  has  ever  experienced  the  stirrings  of  a  foetus  in  utero,  can- 
not mistake  the  movement  of  flatus  for  the  motion  of  the  child ; 
therefore,  after  the  fifth  month,  we  think  there  can  be  little  diffi- 
culty in  distinguishing  the  pregnant  condition  of  the  womb ;  but 
up  to  that  time,  it  is  constantly  involved  in  much  doubt. 

But  fortunately  at  the  present  time,  the  uncertainty  just  spoken 
of  appears  to  be  removed,  by  the  discovery  of  the  heart's  motion, 
and  the  noise  of  the  placental  arteries,  by  means  of  the  stetho- 
scope, by  Kergaradic ;  and  since  verified  by  a  number  of  practi- 
tioners, especially  by  J.  C.  Furguson,  A.  M.,  M.  B.,2  and  Dr. 
Kennedy.3  Both  these  gentlemen  find  that  the  double  beat  of 
the  child's  heart  can  be  distinctly  heard  through  the  uterine  and 
abdominal  parietes,  and  this  as  early  as  between  the  second  and 
third  months ;  and  proportionably  stronger  as  gestation  advances. 
The  following  rules  for  the  use  of  the  stethoscope  appear  to  be 
very  satisfactorily  established: — 

First.  That  the  instrument  can  be  advantageously  used  over 
the  patient's  common  clothes ;  but  that  it  is  better  to  have  but 
a  single  covering  over  the  abdomen,  and  the  patient  lying 
down.4 

Second.  That  in  the  early  months,  the  instrument  must  be  ap- 
plied immediately  above  the  pubes — and  though  the  iliac  arteries 
may  give  the  "bruit  soufflet,"  as  well  as  the  uterine  and  placen- 

1  Dr.  Blundell  informs  us,  that  the  motions  of  the  child  in  utero  can  be  by  the 
designing  so  simulated,  as  to  deceive  those  who  have  had  a  very  enlarged  experi- 
ence in  midwifery:  in  proof  of  this,  he  informs  us  that  a  woman  in  London  de- 
ceived both  the  experienced  Lecturers,  Lowder  and  Mackenzie,  and  they  honestly 
confessed  they  would  have  been  imposed  upon,  had  they  not  ascertained,  by  an 
examination  per  vaginam,  that  the  uterus  was  empty. —  Principles  and  Practice 
of  Obstetricy,  p.  156.  The  case  is  referred  to  in  page  173. 

*  See  Dublin  Med.  Trans.  Vol.  I.  part  1,  New  Series. 
8  See  Dublin  Hospital  Reports,  Vol.  I. 

*  Fodere  recommends  the  application  of  the  ear  to  the  naked  abdomen,  when  it 
can  be  done  with  propriety,  as  the  sounds  are  then  more  distinct. 


OF    QUICKENING.  179 

tary  arteries,  yet  they  can  never  resemble  the  double  stroke  of 
the  heart ;  nor  can  they  be  well  heard,  except  in  the  groin ; 
whereas,  the  other  may  be  heard  over  some  extent  of  the  abdo- 
men ;  especially  in  the  more  advanced  stages  of  pregnancy. 

Third.  That  the  beat  of  the  foetal  heart,  agreeably  to  Mr.  Fur- 
guson,  may  be  heard  in  almost  every  region  of  the  abdomen. 

Fourth.  That  the  beat  of  the  foetal  heart  is  not  always  heard 
in  the  same  place  in  the  same  individual;  that  is,  it  may  be  found 
at  one  point  to-day,  and  at  another  to-morrow,  owing,  doubtless, 
to  the  change  in  the  position  of  the  foetus  itself. 

Fifth.  That  the  pulsations  of  the  child's  heart  are  often  double 
that  of  the  mother's ;  and  its  double  beat  is  well  and  distinctly 
marked,1 

Sixth.  That  a  foetal  heart,  not  exceeding  in  size  a  hazel-nut, 
can  be  distinctly  heard  to  beat  by  the  stethoscope. 

The  value  of  this  discovery,  in  a  medico-legal  point  of  view, 
as  well  as  oftentimes  in  the  common  routine  of  practice,  need 
not  be  commented  on. 

While  on  this  subject,  it  may  be  well  to  mention,  that  Dr. 
Becc'aria  thinks  he  has  discovered  a  new  symptom,  by  which 
pregnancy  in  the  early  months  is  very  certainly  detected.  This 
author  thinks  he  has  observed,  in  many  instances,  during  several 
years'  practice,  a  painful  pulsating  sensation  beset  the  woman, 
in  that  portion  of  the  skull  which  Gall  terms  the  organ  of  ama- 
tiveness;  this  feeling  is  accompanied  by  giddiness  upon  the  least 
motion  of  the  head.  Such  females  as  feel  this  pain  are  sud- 
denly seized  with  it,  and  without  premonition.  It  continues 
some  time,  and  is  followed  by  sleepiness,  which  being  yielded  to 
for  a  short  time  by  the  patient,  she  awakens  free  from  pain,  and 
with  a  great  appetite.  This  pain  returns  daily,  at  about  the  same 
hour,  for  about  eight  days.  It  leaves  the  patient  spontaneously 
and  without  the  aid  of  art.  This  symptom  manifests  itself  with- 
out being  accompanied  with  the  usual  signs  of  pregnancy,  and 
without  the  woman  suspecting  herself  to  be  in  this  situation. — 
(See  Amer.  Jour,  of  Med.  Sci.  for  May,  1831.) 

'  Mr.  Furguson  found,  in  one  instance,  the  beats  of  the  mother's  heart  80,  and 
that  of  the  fetus  136.  In  another,  mother's  90,  foetus  130.  In  another,  the  mo- 
ther's were  100,  and  the  foetus  but  28. 


t 

180  CONDITION   OF   THE   SYSTEM   DURING 


CHAPTER  IX. 


OP  THE  GENERAL  CONDITION  OF  THE  SYSTEM,  AND  THE  EFFECTS  OF 
CERTAIN  REMEDIES  UPON  IT  DURING  PREGNANCY. 

DR.  DENMAN  seems  rather  unwilling  to  call  the  various  affec- 
tions to  which  the  female  is  liable  from  impregnation,  diseases. 
He  says,  "The  state  of  pregnancy  is  an  altered,  but  cannot  with 
propriety  be  called  a  morbid  state."  We  are  of  opinion,  that 
pregnancy  is  not  necessarily  a  disease,  but  that  the  impregnated 
uterus  very  frequently  induces  it  in  other  organs  of  the  body, 
from  a  strong  sympathetic  influence,  though  it  may  be  free  from 
disease  itself. 

The  uterus  being  occupied  with  the  rudiments  of  a  new  being, 
agreeably  to  the  arrangement  of  nature,  cannot  properly  be  said 
to  be  in  a  morbid  condition :  on  the  contrary,  it  is  essential  to 
the  object  of  this  condition,  that  it  preserve  almost  inviolate  its 
healthful  integrity.  For  if  the  uterus  become  diseased,  in  the 
strict  meaning  of  the  word,  the  intentions  of  this  condition  will, 
almost  to  a  certainty,  be  frustrated.  It  therefore  has  a  decided 
power  over  other  parts,  by  exciting  them  to  diseased,  or  at  least 
deranged  action,  while  it  preserves  itself  in  the  most  healthful 
state.  Indeed,  the  healthful  state  of  this  organ  seems  neces- 
sary to  the  power  it  has  of  calling  other  parts  into  sympathy. 

This  is  abundantly  proved  by  the  fact  that  the  process  of  ges- 
tation goes  on,  as  a  general  rule,  best,  when  certain,  or  what  are 
termed  the  rational  signs  of  pregnancy,  are  present,  and  even  in 
full  force:  such  as  nausea,  vomiting,  salivation,  heartburn,  swell- 
ing of  the  breasts,  &c.  &c.,  and  consequently  proving  pregnancy 
to  be  a  healthful  condition.  This  is  a  fact  almost  universally  ad- 
mitted by  the  writers  upon  the  subject  of  midwifery.  "  It  is  a 
popular  observation,"  says  Dr.  Denman,  "confirmed  by  expe- 
rience, that  those  women  are  less  subject  to  abortion,  and  ulti- 
mately fare  better,  who  have  such  symptoms  as  generally  attend 
pregnancy,  than  those  who  are  exempt  from  them,"  p.  225. 

Is  it  not  then  certain,  that  the  uterus  is  in  the  best  health, 
when  it  excites  the  various  parts  concerned  in  the  affections  just 
enumerated?  and  when  it  does  not  move  them  to  sympathy  as 
above  stated,  that  it  is  performing  its  functions  less  healthily: 
since  it  may  be  excited  to  action,  and  very  often  is,  in  the  ab- 
sence of  these  symptoms,  to  abortion  ?  For  habitual  aborters  are 


*'  V 

I 
PKEGNAXCY,    AND   THE    EFFECTS   OF   REMEDIES.    181 

very  rarely  attacked  with  the  more  common  affections  belonging 
to  pregnancy.1 

The  uterus,  when  impregnated,  produces  commotions  in  vari- 
ous degrees,  in  other  portions  of  the  system,  while  it  preserves 
itself  in  the  most  healthy  condition,  as  if  these  various  sympathies 
were  intended  to  divert  all  evil  from  it,  that  the  great  object  of 
nature,  (the  propagation  of  the  species,)  should  not  be  circum- 
vented with  too  much  facility.  Very  frequently,  in  civilized  life, 
and  not  uncommonly  in  savage  life,  the  "breeding  symptoms" 
are  very  often  called  forth ;  now,  it  is  not  reasonable  to  suppose 
that  all  the  severe  sufferings  to  which  the  pregnant  woman  is 
subjected,  can  be  idly  instituted,  without  a  physical  end,  or  a 
moral  purpose !  It  cannot  be  that  the  severe  privations,  and  the 
absolute  evils  of  gestation,  should  have  been  intended  as  an  afflic- 
tion without  an  object ! 

The  sympathies  called  forth  by  pregnancy,  though  they  are, 
strictly  speaking,  but  chains  of  morbid  actions,  so  far  as  the  parts 
immediately  affected  are  concerned,  yet  they  are  not,  like  most 
morbid  actions,  called  forth  by  a  morbid  cause ;  and  we  must  still 
insist,  that  pregnancy,  abstractly  considered,  is  not  a  disease. 
For  we  have  already  shown,  that  the  uterus,  the  part  most  im- 
mediately and  extensively  concerned  in  the  process  of  gestation, 
must  preserve  its  healthy  powers,  that  this  function  shall  not 
cease.  It  is,  therefore,  unlike  any  other  process  in  the  human 
body;  for  it  seems  to  provoke  disease  in  other  parts,  in  order  to 
preserve  the  perfection  of  its  own  operations. 

The  disturbances  arising  from  impregnation  have  the  tendency 
to  prevent  plethora,  or  to  divert  excitement.  And  these  objects 
are  chiefly  effected  through  the  agency  of  the  stomach,  the  part 
most  generally  subjected  to  this  kind  of  vassalage.  Hence,  nau- 
sea, vomiting,  loss  of  appetite,  disgust,  or  loathings,  or  longing 
for  certain  unnutritious  substances,  &c.  These  affections  are  in- 
stituted, that  the  quantity  of  circulating  fluids  may  be  lessened, 
and  excitement  diverted;  and  thus  prevent  the  evils  so  sure  to 
attend  that  condition  of  the  system  called  plethora.  Now,  if  the 
subjects  be  closely  examined,  it  will  pretty  generally  be  found, 
that  the  sympathetic  affections  are  violent,  in  proportion  to  the 
necessity  of  subduing  this  state  of  fulness,  or  uterine  excitement. 
We  may  be  told,  that  many  women  "breed"  without  any,  or 
but  very  few  of  the  affections  which  commonly  attend  pregnancy. 
This  is  admitted;  but  in  such  cases  there  is,  perhaps,  no  necessity 
for  instituting  this  subduing  process ;  as  there  may  be  little  or  no 
tendency  to  the  fulness  spoken  of. 

1  It  must,  however,  be  admitted,  that  there  are  exceptions  to  this  rule;  we  have 
seen  several  instances  of  extreme  eicknessof  stomach,  vomiting,  &c-,  attend,  when 
the  patients  have  aborted,  and  this  repeatedly. 


Generally,  the  women  who  are  exempt  from  this  common 
penalty,  are  those  who  possess  great  physical  powers,  and  are  in 
the  habit  of  constantly  employing  them.  In  these  cases,  the  same 
end  is  answered  by  other  means.  The  excitability  of  the  sys- 
tem is  expended  by  the  regular  application  of  the  stimulus  of 
exercise ;  and,  consequently,  that  state  of  irritability  of  the  mus- 
cular and  vascular  systems,  so  injurious  at  this  period,  is  pre- 
vented. Besides,  people  who  employ  their  physical  powers  in 
useful  exertion  have  few  provocatives,  save  that  of  regular  ex- 
ercise and  regular  rest,  to  produce  appetite ;  no  artificial  condi- 
tion of  the  stomach  is  created ;  they  satisfy  their  cravings  by  a 
simple  but  nutritious  diet;  and  no  more  blood  is  formed  than  is 
sufficient  for  the  exigencies  of  the  system. 

In  these  cases,  also,  the  irritability  of  the  uterus  never  be- 
comes so  excessive,  as  where  the  contrary  life  is  led.  For  the 
uterus,  being  a  muscle,  participates,  like  the  other  muscles  of  the 
body,  in  the  general  benefit  derived  from  healthful  and  regular 
occupation  and  exercise.  The  nervous  system  has  less  mobility, 
for  the  same  reason ;  of  course,  the  uterus  will  be  less  disposed 
to  be  thrown  into  contraction,  by  the  application  of  either  physi- 
cal or  mental  stimuli;  consequently,  there  will  be  less  disposition 
to  abortion. 

With  those  who  lead  indolent  lives,  and  who  feed  luxuriously, 
the  case  is  very  different.  In  such,  more  blood  will  be  made 
than  can  advantageously  be  employed;  consequently,  there  will 
be  "  plethora" — and  not  only  plethora,  but  augmented  irritability; 
and,  therefore,  a  liability  on  the  part  of  the  uterus  to  be  thrown 
into  contraction,  by  smaller  causes,  sometimes,  than  ordinary. 

Now,  should  such  females  not  be  visited  by  the  common  affec- 
tions of  gestation,  the  liability  to  abortion  will  be  increased  in 
proportion  to  the  disposition  of  the  system  to  become  plethoric. 
Hence,  the  truth  of  the  remark,  that  "those  women  are  less  sub- 
ject to  abortion,  and  ultimately  fare  better,  who  have  such  symp- 
toms as  generally  attend  pregnancy,  than  such  as  are  exempt 
from  them." 

We  know  a  lady  that  is  easily  provoked  to  abortion,  who  can 
tell,  soon  after  the  stoppipg  of  her  catamenia,  whether  she  will 
carry  her  child  or  not,  by  the  state  of  her  stomach.  If  she  have 
no  morning  sickness,  vomiting,  loss  of  appetite,  or  disgust,  she 
is  certain  to  abort.  She  has  now  acquired  sufficient  knowledge 
of  herself  to  prevent  this  accident ;  and  whenever  she  faithfully 
acts  up  to  the  dictates  of  her  reason  and  experience,  she  is  sure 
to  carry  her  child  safely. 

If,  after  the  interruption  of  her  menses,  she  do  not  become  af- 
fected with  the  common  consequences  of  impregnation,  she  in- 
stantly reduces  the  ordinary  quantity  and  quality  of  her  food ; 
drinks  nothing  but  water;  keeps  her  bowels  soluble;  and  some- 


PREGNANCY,  AND  THE  EFFECTS  OF  REMEDIES.  183 

times,  but  not  always,  loses  a  little  blood ;  (but  this  never  with- 
out the  advice  of  her  physician ;)  uses  very  little  exercise,  lest 
she  produce  fatigue ;  in  a  word  so  conducts  her  regimen  as  to 
very  much  reduce,  if  not  entirely  prevent,  plethora;  and  she  so 
manages  her  physical  exertions  as  not  to  convert  them  into  un- 
usual stimuli  to  her  nervous  and  muscular  systems. 

But,  at  other  times,  when  she  becomes  pregnant,  and  has  the 
ordinary  accompanying  signs,  she  takes  no  extraordinary  trouble 
to  regulate  the  condition  of  her  system,  as  she  finds  they  are  al- 
most always  sufficient  to  subdue  the  tendency  to  plethora.  But 
should  she  feel  headach,  or  other  marks  of  fulness,  she  loses  a 
little  blood,  or  eats  less. 

During  pregnancy,  the  system  is  in  a  state  of  constant  stimula- 
tion from  this  very  cause.  First,  there  is  the  stimulus  of  disten- 
tion  constantly  operating,  from  the  first  six  weeks  to  the  full  pe- 
riod of  utero-gestation.  This  is  the  most  obvious  in  the  first  few 
months ;  and,  for  this  reason,  the  uterus  yields  with  more  reluc- 
tance at  this,  than  at  any  subsequent  period,  either  from  its  own 
specific  density,  or  from  the  smallness,  as  well  as  feebleness,  of 
the  distending  cause  within.1  Hence,  in  the  first  few  months  of 
pregnancy,  the  sympathetic  affections  are  more  violent  than  at 
the  after  periods.  2d.  Joined  to  the  stimulus  of  distention,  is 
that  disturbance  which  is,  and  must  be,  consequent  upon  the 
change  of  position  of  all  the  abdominal  viscera,  and  which  is 
sometimes  very  considerable.  (See  section  on  the  pain  in  the 
right  side  of  pregnant  women.)  3d.  The  constant,  though  not 
uniform  pressure  upon  the  intestines,  both  above  the  fundus,  and 
below  its  posterior  and  lateral  portions,  giving  rise  sometimes 
to  many  unpleasant  symptoms ;  such  as  cramping  pains,  from  the 
unequal  distention  of  the  bowels;  constipation;  diarrhoea;  &c.2 

'  So  reluctantly  does  the  uterus  yield  at  this  period,  sometimes,  that  much  in- 
convenience is  experienced  on  the  part  of  the  patient,  from  severe  alternating  pains 
in  this  part,  which  are  tranquillized  with  difficulty,  by  blood-letting,  opium,  &c. 
At  other  times,  it  absolutely  refuses  to  yield  farther  than  a  certain  point;  con- 
tractions are  excited,  and  the  ovum  eventually  expelled — this  is  one  of  the  causes 
of  abortion. 

1  "There  is  every  reason  to  believe  that  the  uterus,  and,  therefore,  its  cavity,  is 
not  enlarged  solely  by  the  distending  power  of  the  ovum;  as,  in  cases  of  extra-ute- 
rine pregnancies,  it  has  been  known  to  be  much  larger  than  in  the  natural  state, 
and  to  be  lined  with  the  decidua." — Review  of  Dewees  on  Females.  N.  Amer. 
Med.  &  Surg.  Jour.  Vol.  III.  p.  302. 

In  reply  to  the  above  critic,  it  is  but  necessary  to  observe  that  I  have  no  where 
asserted  that  the  increase  of  the  uterus  wai  owing  solely  to  the  distending  power  of 
the  ovum.  T  have  only  declared  that  the  uterine  cavity  was  enlarged  by  the  ovum ; 
and  that  it  is,  in  every  way,  evident,  as  the  most  perfect  relation  between  them  is 
constantly  established  after  a  certain  period  of  pregnancy.  Now,  if  the  ovum  do 
not  make  room  for  itself,  it  must  be  evident  some  other  power  must  exist  for  this 
purpose.  Can  any  other  power  be  pointed  out?  Is  it  not  clear ,to  demonstration, 
that  the  ovum  is  the  agent,  when,  if  this  be  broken,  and  the  liquor  amnii  dis- 
charged, the  uterine  parietes  contract  to  the  altered  size  of  the  ovum  ?  No, 
says  the  reviewer ;  for  "  the  uterus  is  found  to  be  much  larger  than  in  the  natural 


184    GENERAL  CONDITION  OF  THE  SYSTEM  DURING 

The  combination  of  these  causes  keeps  the  system  in  a  state  of 
constant  excitement ;  the  pulse  is,  therefore,  almost  always  acce- 
lerated. The  nervous  system  directly,  and  the  arterial  indirectly, 
are  always  found  to  bear  stimuli  ill.  Hence,  in  their  exhibition 
at  such  periods,  there  is  much  caution  necessary. 

The  young  practitioner  should  never  lose  sight  of  the  im- 
portant fact  just  mentioned,  if  he  expect  to  be  successful  in  the 
treatment  of  the  diseased  of  the  female  at  such  periods.  We  have 
known  many  errors  committed  for  want  of  due  attention  to  this 
state  of  the  female  system :  some  of  greater,  and  others  of  minor 
importance ;  but  all'errors  of  this  kind  should  be  avoided  with 
great  care. 

To  show  the  susceptibility  of  the  system  to  stimuli  at  this  pe- 
riod, in  some  cases,  we  will  relate  one  instance  of  many  of  a  simi- 
lar kind,  which  have  fallen  within  our  own  knowledge.  Mrs. 
,  pregnant  with  her  sixth  child,  and  at  the  eighth  month  com- 
plete of  utero-gestation,  complained  suddenly  of  sickness,  accom- 


state,  in  cases  of  extra-uterine  pregnancies."  Can  the  reviewer  bring  any  case  of 
extra-uterine  pregnancy,  where  the  uterine  cavity  was  found  of  a  size  equal  to  that 
at  which  it  would  have  arrived,  had  the  pregnancy  been  a  uterine  one?  We  are 
sure  he  cannot. 

That  the  uterus  becomes  larger  in  cases  of  extra-uterine  conceptions,  we  adroit 
without  hesitation ;  for,  in  such  cases,  blood  is  sent  to  its  parietes,  and  the  decidua 
is  formed,  as  in  a  natural  pregnancy ;  and  hence  its  enlargement  in  such  cases. 
But  this  proves  no  more  than  is  here  set  down ;  namely,  that  the  uterus  is  larger 
than  in  its  natural  state;  and  this  is  all  that  has  ever  been  asserted  by  the  relators 
of  such  cases.  Let  us  now  ask,  does  this  prove  any  thing  contrary  to  what  I  have 
declared  upon  this  point?  All  that  has  been  said  upon  the  distention  of  the  ute- 
rus, therefore,  remains  uncontradicted ;  for  I  have  never  advanced  that  the  increase 
of  this  organ  from  gestation  was  solely  owing  to  the  ovum.  On  the  contrary,  I 
have  maintained  the  influence  of  the  increased  quantity  of  blood,  and  the  con- 
sequent augmentation  of  the  vessels  in  the  proper  substance  of  the  uterus,  as  con- 
tributing materially  to  its  enlargement;  and  to  these  two  causes  do  I  still  attri- 
bute the  enlargement  of  the  uterus  in  a  natural  or  healthy  pregnancy. 

The  reviewer  farther  declares,  "  It  is  not  correct  to  assert  that  the  greater  suffer- 
ings of  the  woman,  in  the  earlier  periods,  depend  upon  the  stimulus  of  distention 
being  greater  at  that  time;  as,  in  some  individuals,  these  sympathetic  affections 
appear  before  we  have  any  proofs  of  the  ovum  having  reached  the  uterine  cavity." 
— Ib.  To  this  logic  we  would  only  answer,  that,  if  there  be  "  no  proofs  of  the 
ovum  having  reached  the  uterine  cavity,"  there  can  certainly  be  none  that  it  has 
not ;  and,  consequently,  we  have  as  much  right  to  the  positive  assumption,  were  it 
in  any  way  important  to  our  views,  as  the  reviewer  has  to  the  negative.  But  this 
is  of  little  consequence.  We  believe  we  are  borne  out  by  all  physiologists,  when 
we  assert  that  later  than  thirty  days  has  never  been  fixed  for  the  ovum  to  gain 
possession  of  the  uterine  cavity;  and  we  believe  that  all  observation  confirms  the 
declaration,  that  sooner  than  this,  the  rational  signs  of  pregnancy  never  appear ; 
indeed,  six  weeks  is  very  early  for  these  symptoms  to  manifest  themselves.  Nor 
is  it  of  any  kind  of  consequence  to  the  subject  in  question,  whether  the  distention 
of  the  uterine  cavity  be  effected  by  the  ovum,  or  by  any  other  agency,  since  the 
reviewer  himself  admits  that  the  uterus  increases,  even  in  extra-uterine  concep- 
tions. The  ovum,  however,  must  always  be  regarded  as  infinitely  the  most  com- 
mon cause,  and  was  consequently  chosen  to  illustrate  the  principle  contended  for. 
And  we  may  add,  that  when  the  signs  of  pregnancy  appear  earlier  than  is  here 
stated,  they  are  the  exceptions  to  this  rule. 


\ 

PREGNANCY,"  AND   THE   EFFECTS    OF   EEMEDIES.    185 

panied  by  a  distressing  sensation  of  the  stomach ;  she  was  advised, 
by  a  young  practitioner  of  medicine,  who  happened  to  be  present, 
to  take  a  little  pretty  strong  brandy  and  water;  which  he  accord- 
ingly prepared,  and  gave  to  her. 

She  had  not  swallowed  the  mixture  more  than  fifteen  minutes, 
before  she  felt  the  distressing  sensation  increase,  though  the  nau- 
sea was  abated;  at  the  same  time  she  experienced  a  confusion, 
and  severe  pain  in  the  head,  which  seemed  more  concentrated  in 
the  forehead,  immediately  above  the  eyes ;  a  dimness,  or  rather 
a  temporary  loss  of  sight,  with  strong  twitchings  in  the  muscles 
of  the  arms  and  legs. 

The  physician,  as  well  as  the  family,  became  alarmed  lest  this 
should  eventuate  in  a  "fit;"  and  we  were  requested  to  see  the 
lady  immediately.  When  we  visited  her,  she  was  labouring  un- 
der the  above  named  symptoms,  and  which  had  been  gradually 
increasing  from  the  beginning  of  the  attack. 

We  found  her  with  an  accelerated  pulse ;  a  flushed  face,  and 
considerable  confusion  of  intellect.  The  remedy,  in  such  a  case, 
could  not  be  mistaken.  Her  arm  was  immediately  tied  up,  and 
blood  abstracted,  until  her  head  and  senses  were  perfectly  re- 
lieved; it  did  not,  however,  require  more  than  fourteen  or  fifteen 
ounces  of  blood  to  effect  this.  She  had  no  return  of  any  unplea- 
sant symptom  after  that  evening. 

So  much  does  pregnancy  modify  the  affections  of  the  system, 
that  even  the  sensations  called  nervous  can  rarely  be  relieved  by 
the  usual  remedies,  however  successful  they  may  have  been  with 
the  same  patient  at  other  times,  but  under  different  circum- 
stances. The  common  symptoms  by  which  hysteria  shows  itself, 
such  as  palpitation  of  the  heart ;  a  sense  of  suffocation ;  difficulty 
of  swallowing,  &c.,  can  rarely  be  controlled  by  the  common  reme- 
dies, unless  they  are  anticipated  by  a  bleeding  of  a  greater  or 
less  extent.  This  should  be  borne  in  mind:  for  success  will  not 
follow  the  use  of  remedies,  without  attention  be  paid  to  it. 

But  the  susceptibility  of  the  system  to  stimuli  during  preg- 
nancy is  more  evident  when  the  woman  is  attacked  with  an 
acute  disease:  such  as  fever.  To  relieve  her,  at  this  time,  is 
found  more  difficult  always,  than  at  any  other;  for  the  system  is 
now  so  susceptible,  so  disposed  from  the  circumstances  of  preg- 
nancy to  maintain  morbid  action,  that  remedies  of  the  most  ap- 
propriate kind  succeed  with  difficulty.  And  if  it  be  attempted 
to  accelerate  convalescence  by  tonics,  even  of  the  mildest  sort, 
they  are  almost  sure  to  disappoint  the  practitioner,  if  they  should 
not  even  recall  the  disease. 

Nothing,  perhaps,  shows  the  difficulty  of  employing  tonics 
during  pregnancy,  more  than  the  want  of  success  of  the  Peruvian 
bark  in  intermittents.  In  substance,  we  scarcely  ever  succeed 
in  arresting  the  paroxysms,  as  we  might  calculate  to  do  in  ordi- 


186  OF    BLEEDING   DURING   PREGNANCY. 

nary  cases,  unless  its  exhibition  has  been  succeeded  by  very 
ample  depletion.  We  have  seen  a  number  of  instances,  where 
an  intermittent  has  been  quickly  converted  into  a  remittent,  by 
the  exhibition  of  the  bark.  Indeed,  it  is  hardly  ever  safe  to  trust 
it  even  after  very  liberal  evacuations.  The  sulphate  of  quinine, 
however,  is  less  objectionable,  or  less  treacherous. 

In  a  word,  we  rarely  use  tonics  of  the  more  powerful  kind,  in 
the  convalescence  of  females,  after  acute  diseases,  when  compli- 
cated by  pregnancy,  especially  in  the  earlier  months.  After  the 
fifth  month,  up  to  the  full  period,  the  system  is  less  irritable. 
For  soon  after  quickening,  almost  all  the  sympathetic  affections 
begin  to  moderate ;  and  sometimes,  nay,  very  often,  cease  alto- 
gether. 

This,  it  is  probable,  is  owing  to  the  following  causes ; — 1st. 
From  the  uterus  now  making  greater  demands  upon  the  system 
at  large  for  blood ;  from  the  increased  size  of  itself  and  foetus; 
and  consequently  relieving,  in  a  degree,  the  state  of  plethora. 
2d.  By  the  system  having  become  more  familiar  to  the  peculiar 
stimulus  of  pregnancy,  from  its  long  continuance.  3d.  To  less 
irritation  being  experienced  by  the  greater  disposition  of  this 
organ  to  be  distended.  For,  after  the  fifth  month,  the  resistance 
of  the  fundus  and  body  is  less ;  1st.  From  its  increase  of  vascu- 
larity :  and,  secondly,  from  the  ovum  augmenting  in  power. 
Hence  the  melioration  of  symptoms  after  the  fifth  month.  We 
will  now  consider  the  effects  of  certain  remedies  during  gesta- 
tion. 

-PIT    ,:-:>.'/     •T'Jf'J-f   v'.l  .u;^ 

ls£.   Of  Bleeding  during  Pregnancy. 

From  what  we  have  said,  it  follows  that  the  female  constitu- 
tion, during  pregnancy,  has  great  susceptibilities,  and  even  pecu- 
liarities, which  are  highly  important  to  be  known  and  regarded, 
especially  when  prescribing  for  an  acute  disease.  The  process 
of  sanguification  is  much  more  rapid  during  this  period ;  as  all 
the  functions  of  the  body  are  more  quickly  performed.  Hence, 
at  this  time  they  bear  so  well  the  loss  of  blood ;  hence,  the  more 
frequent  necessity  of  abstracting  it ;  and  hence  the  difficulty  of 
overcoming  the  morbid  actions  of  the  system  at  such  times. 

There  is,  very  often,  much  clamour  raised  against  this  opera- 
tion ;  the  depletion  of  the  pregnant  woman.  This  is  sometimes 
so  great  as  to  render  it  extremely  difficult  to  subdue  their  dis- 
eases.1 This  prejudice,  for  so  it  truly  is,  is  founded  upon  false 
views  of  the  functions  of  the  uterus,  and  the  economy  of  the  foetus, 

1  The  young  or  inexperienced  practitioner  must  not  be  betrayed  into  over  bleed- 
ing in  cases  of  pregnancy,  by  the  sizy  appearance  of  the  blood;  for  such  is  the 
indomitable  nature  of  the  blood  vessels,  that  the  blood  would  appear  sizy  to  the 
last  drop  in  the  body. 


OF    BLEEDING   DURING    PREGNANCY.  187 

during  the  period  of  utero-gestation.  It  is  imagined,  that  every 
ounce  of  blood  the  mother  loses  deprives  the  foetus  of  a  certain 
portion  of  it ;  consequently,  that  we  should  be  very  sparing  of 
this  fluid,  that  we  may  not  rob  the  foetus  of  its  due  quantity  of 
nourishment.  On  this  account,  the  clamour  of  the  friends  fre- 
quently arrests  the  lancet,  when  its  employment  is  most  essential 
to  the  welfare  of  the  mother. 

There  are  few  mistakes  of  greater  magnitude  than  the  one  just 
noticed;  and,  though  founded  in  error,  it  has,  nevertheless,  often 
prevented,  or  very  much  interfered  with  the  free  and  unbiassed 
practice  of  medicine.  It  very  often  causes  the  young  practi- 
tioner to  abandon  some  of  the  best  established  principles  in  the 
practice  of  his  art ;  namely,  1st,  that  women  bear  the  loss  of 
blood  better,  when  pregnant,  than  at  any  other  period ;  and 
2dly,  that  all  the  acute  diseases  by  Avhich  they  may  be  attacked 
require  a  more  extensive  use  of  the  lancet.  If,  then,  the  inter- 
ference of  friends  interrupt  the  free  exercise  of  the  judgment, 
the  practitioner  is  reduced  to  the  office  of  a  nurse;  for  it  is  not 
he  who  prescribes,  but  the  friends  of  the  patient ;  while  all  the 
responsibility  rests  upon  his  shoulders.  We  have  known  much 
mischief  produced  by  yielding  to  these  mistaken  views  of  the 
animal  economy,  at  this  time. 

It  should  be  recollected,  that  the  circulation  through  the 
uterus  has  most  wisely  been  rendered  almost  independent  of 
the  contingent  condition  of  the  general  circulation  of  the  system ; 
and  that  no  one  viscus  in  the  body  is  so  little  influenced  by 
qhanges  in  this  important  function,  as  this  organ,  during  the 
whole  period  of  utero-gestation.  The  uterus  contrives,  if  we 
may  use  the  expression,  to  make  its  demands  upon  the  general 
mass  always  successfully;  or,  at  least,  so  long  as  there  is  any 
thing  to  ask  for;  hence,  when  almost  every  other  organ  is  but 
sparingly  supplied,  we  find  the  uterus  abundantly  furnished. 
Who,  in  the  practice  of  midwifery,  has  not  seen  a  fully-developed 
foetus  yielded  by  a  mother  in  the  last  stage  of  a  wasting  disease, 
like  phthisis  pulmonalis,  and  where  the  quantity  of  circulating 
fluids  was  extremely  diminished  ? 

Is  it  to  be  supposed,  then,  in  such,  and  in  similar  cases,  that 
this  could  have  happened,  had  the  uterus  had  no  more  than  a 
common  participation  in  the  distribution  of  the  blood  ?  Certainly 
not ;  since  the  quantity  in  every  other  portion  of  the  body  was 
reduced,  by  being  deprived  of  part  of  their  usual  supplies.  But 
it  may  be  said  that  the  uterus,  in  this  respect,  only  enjoys  the 
property  of  amassing  supplies,  in  common  with  other  viscera ; 
let  this  be  so;  it  is  not  a  part  of  our  present  purpose  to  inquire 
into  it ;  all  that  we  insist  on  at  this  moment  is,  that  the  uterus 
absolutely  possesses  this  power. 


188  OF    PURGING    DURING    PREGNANCY. 

We  may  be  told  that  the  foetus  is  by  no  means  so  secure  as  is 
represented,  when  the  mother  Buffers  considerable  losses  of  blood ; 
and  they  will  attempt  to  illustrate  this,  by  showing  that  the  child 
often  perishes  from  uterine  hemorrhages.  This  is  true ;  but  it 
does  not  interfere  with  our  remark ;  for  we  have  not  said  that 
the  uterus  cannot  be  exhausted  of  blood,  if  blood  be  taken  di- 
rectly from  it,  as  in  floodings :  we  have  only  declared,  that  when 
this  fluid  is  drawn  from  the  general  system,  as  in  bleedings  per- 
formed for  the  relief  of  disease,  that  very  large  quantities  might 
be  abstracted,  without  making  the  uterus  give  up  any  portion  of 
what  it  absolutely  possesses ;  and  this  is  strictly  true.  But,  on 
the  other  hand,  it  must  not  be  supposed  that  pregnancy,  merely 
as  such,  requires  blood-letting.  This  error  is  as  great  as  the 
one  we  have  just  attempted  to  remove;  for  we  make  it  a  con- 
stant rule  in  practice  to  discountenance  blood-letting,  unless 
there  exist  some  inconvenience  or  disease  to  demand  it. 


2d.   Of  Purging  during  Pregnancy. 

)v  .  •  '.    ;':  - 

The  pregnant  woman  does  not  bear  purging  so  well  as  one 
who  is  not  so:  or  rather,  if  this  operation  be  carried  very  far, 
there  is  a  risk  of  producing  abortion,  owing  to  the  strong  consent 
between  the  uterus  and  rectum.  Hence,  the  occurrence  some- 
times of  this  accident,  from  a  profuse  diarrhoea,  or  a  violent 
dysentery.  Therefore,  some  caution  is  required,  in  treating  the 
diseases  of  pregnant  females  by  purging ;  for  if  carried  to  a  great 
extent,  it  may  do  mischief.  But  let  us  be  understood  exactly  on 
this  head,  lest  we  deprive  females  of  the  advantages  of  this  re- 
medy, in  the  acute  forms  of  disease.  We  mean  that  a  pregnant 
woman  would  not  bear,  with  safety,  as  much  purging,  as  if  she 
were  not  pregnant ;  yet  she  bears  it  with  advantage,  when  car- 
ried to  a  considerable  extent,  especially  if  tenesmus  be  not  ex- 
cited, either  by  the  quality  of  the  drug  employed,  or  by  the 
accidental  severity  of  the  operation  of  a  medicine,  otherwise 
generally  eligible.  In  a  word,  we  believe  that  a  pregnant  woman 
will  bear,  without  risk,  any  common  or  necessary  degree  of  pur- 
ging, unless  she  be  prone  to  abortion. 

We  should  suggest  caution  in  the  choice  of  purgative  medi- 
cines, rather  than  forbid  the  employment  of  this  evacuation,  as  a 
remedy;  for,  with  the  pregnant  woman,  much  depends  upon  the 
selection.  All  such  as  act  with  great  force  upon  the  bowels, 
should  be  avoided;  such,  for  instance,  as  are  classed  among  the 
drastic  purgatives,  as  scammony,  gamboge,  colocynth,  aloes, 
&c. ;  because  each  of  these  produces,  during  its  operation,  great 
irritation  in  the  rectum,  and  very  frequently  excites  tenesmus. 


EMETICS  DURING   PREGNANCY.  189 

It  is  this  peculiar  irritation  which  renders  any  cathartic  unsafe 
that  might  produce  it;  no  matter  to  what  class  of  cathartics  it 
may  belong ;  for,  if  castor  oil,  magnesia,  or  any  other  mild  ca- 
thartic were  to  produce  this  effect,  it  would  be  as  equally  im- 
proper, as  any  of  the  drugs  prescribed  above. 

Hence  we  see  abortion  frequently  occur  from  dysentery ;  and 
but  very  rarely  from  diarrhoea,  however  profuse.  Cases  of  habi- 
tual abortion,  which  are  preceded  by  severe  diarrho3a,  might  be 
considered  as  exceptions  to  this  rule ;  but  this  is,  perhaps,  more 
specious  than  just.  For  in  all  the  instances  which  we  have  wit- 
nessed of  this  kind  of  diarrhoea,  there  was  more  or  less  tenesmus 
accompanying  it ;  and  it  is  with  us  a  doubtful  point,  whether  this 
diarrhoea  is  not,  in  such  cases,  a  concomitant,  rather  than  a 
cause.  For  there  is  no  fact  better  established,  than  that  there 
exists  a  strong  sympathy  between  the  uterus,  (and,  perhaps,  the 
mouth  of  this  organ  particularly,)  and  the  rectum.  We  witness 
this  oftentimes  in  the  commencement  of  labour;  during  its  pro- 
gress, or  towards  its  termination. 

We  have  more  than  one  patient,  whose  labours  always  com- 
mence with  diarrhoea ;  that  is,  so;  soon  as  the  os  uteri  is  stimu- 
lated to  dilatation,  the  bowels  yield.  Now,  in  abortion,  there 
must  always  exist  some  irritation  at  the  os  uteri,  or  it  would  not 
yield  to  the  impulses  of  the  fundus  and  body  of  this  organ,  for 
it  is  by  no  means  a  mechanical  operation.  And  so  soon  as  this 
nisus  is  perceived,  (for  the  uterus  prematurely  throwing  off  its 
contents,  is  a  kind  of  tenesmus  of  this  organ,)  the  rectum  sym- 
pathizes with  the  uterus,  and  a  diarrhoea,  with  tenesmus,  is  pro- 
duced. 

If  this  be  objected  to,  by  saying,  that  abortion  is  sometimes 
prevented  by  the  application  of  opium  to  the  rectum,  thereby 
removing  the  disease,  or  quieting  the  irritation  which  invited  the 
action  of  the  uterus ;  we  would  answer,  there  is  not  the  smallest 
proof  from  this  circumstance;  since  the  sympathy  between  these 
parts  is  reciprocal;  and,  consequently,  when  a  remedy  is  applied 
to  the  one  it  will  influence  the  other.  In  proof  of  this,  how  often 
do  we  successfully  apply  remedies  to  the  rectum,  when  we  mean 
its  effect  shall  be  felt  by  the  uterus  alone? 

We  believe,  then,  it  is  not  so  much  the  frequency  of  the  dis- 
charges from  the  bowels  produced  by  the  operation  of  purgative 
medicine  that  does  the  mischief  in  pregnancy,  as  the  peculiar, 
and  oftentimes  severe  irritation  it  produces  in  the  rectum. 

* 

3t?.     Of  Emetics  during  Pregnancy. 
Emetics  should  be  given  sparingly  to  pregnant  women :  they 


190  OP   BLISTERS   DURING   PREGNANCY. 

are  rarely  eligible  after  the  fifth  month,  and  should  only  be  con- 
sidered as  remedies  of  necessity.  Towards  the  last  months  of 
pregnancy,  their  operation  in  properly,  or  freely  evacuating  the 
stomach,  is  oftentimes  uncertain,  as  this  organ  can  be  very  little 
aided  in  its  efforts  by  the  other  powers  concerned  in  this  ope- 
ration ;  and  from  the  abdominal  muscles  being  very  much  upon 
the  stretch,  much  pain  is  experienced  in  their  contractions  during 
the  efforts  to  vomit,  followed,  sometimes,  by  severe  cramping 
pains. 

We  have  known  severe  and  permanent  pain  produced  by  the 
exhibition  of  an  emetic  at  the  latter  period  of  utero-gestation, 
and  from  which  the  patient  was  not  entirely  relieved  until  the 
termination  of  her  labour. 

In  the  early  months,  nature  oftentimes  establishes  this  process 
for  wise  purposes;  but  even  then,  the  action  of  the  stomach  is 
rather  frequently,  than  violently  excited;  and  it  may  generally 
b«  said,  there  is  more  nausea  than  vomiting.  But,  even  in  the 
early  periods,  emetics  are  to  be  used  with  caution ;  and  when 
determined  on,  the  ipecacuanha  should  be  made  choice  of.1 


4th.     Of  Blisters  during  Pregnancy. 

Blisters  are  to  be  used  with  great  caution  with  pregnant  wo- 
men :  owing  to  the  great  excitability  of  their  systems,  they  pro- 
duce a  great  deal  of  pain  during  their  operation ;  and  this  is  not 
always  followed  by  benefit. 

During  pregnancy,  blisters  are  much  more  apt  to  produce 
strangury  than  at  other  times ;  and  when  this  occurs  it  is  almost 
sure  to  be  followed  by  the  most  distressing  and  untoward  symp- 
toms. We  have  seen  entire  retention  of  urine  follow  their  use ; 
which  has  been  only  relieved  by  the  catheter ;  and  attended  with 
such  distressing  inclination,  and  violence  of  effort,  as  to  be  only 
surpassed  by  the  pains  of  labour.  Bloody  urine  has  sometimes 
followed  the  use  of  a  blister ;  and  a  discharge  of  mucus  from  the 
internal  face  of  the  bladder  has  continued  for  a  long  time  after. 
It  is  true  these  are  extreme  cases;  but  they  nevertheless  occur, 
and  should,  therefore,  suggest  a  great  deal  of  caution  in  their  em- 
ployment, especially  in  the  more  advanced  periods  of  gestation. 

We  think  we  have  seen  two  instances  of  premature  labour  from 

1  A  practitioner  was  called,  about  two  years  since,  to  a  lady  of  my  acquaint- 
ance, who  was  in  her  last  month  of  pregnancy.  He  said  she  was  very  bilious, 
and  must  take  an  emetic.  This  he  gave  her,  and  it  vomited  her  so  severely  as  to 
induce  the  action  of  the  uterus,  which  did  not  cease  until  premature  labour  took 
place,  and  finally  delivery  was  the  consequence:  both  mother  and  child  had  nearly 
fallen  a  sacrifice  to  this  mischievous  proceeding. 


FEBRILE   CONDITION,  ETC.  191 

the  action  of  blisters ;  yet  we  must  acknowledge  they  have  been 
advantageously  employed  to  prevent  abortion.1 


CHAPTER  X. 

ON  SOME  OF   THE   DISORDERS  OF   PREGNANCY. 

EVERT  experienced  accoucheur  is  aware,  and  it  is  highly  im- 
portant to  the  young  practitioner  to  be  informed,  that  the  preg- 
nant state  imposes  a  peculiar  character  upon  many  common  af- 
fections of  the  system;  and  that  it  gives  rise  to  a  morbid  condi- 
tion of  some  particular  organs,  certainly  during  a  part,  and  some- 
times during  the  whole  term,  of  its  continuance. 

We  shall  endeavour  to  point  out,  in  what  follows  under  this 
head,  the  peculiarities  just  spoken  of;  together  with  the  particu- 
lar plan  or  modification  of  treatment  in  each  of  these  affections, 
that  the  state  of  conception  requires ;  for  it  is  essential  to  success- 
ful practice  that  the  changes  effected  in  the  nervous  and  sangui- 
ferous  systems  from  this  cause  be  well  understood.  We  shall, 
therefore,  treat  of  the  most  common,  as  well  as  of  the  most  im- 
portant of  these  diseases,  as  modified  by,  or  originating  from,  the 
gravid  state  of  the  uterus.  We  have  already  pointed  out  the  re- 
strictions and  precautions  that  certain  therapeutical  agents  re- 
quire, under  the  circumstances  now  contemplated. 

SECT.  I. — On  the  Febrile  Condition  of  the  System  during 
Pregnancy. 

From  what  has  just  been  said  it  would  appear,  that  the  system 
of  the  pregnant  woman  is  almost  always  labouring  under  a  degree 
of  excitement  not  common  to  it  at  other  periods ;  and,  conse- 
quently, that  it  will  ill  bear  stimuli.  But  this  acceleration  of 
pulse,  and  susceptibility  to  stimuli,  must  not  be  looked  upon  as 
a  state  of  absolute  disease,  when  nothing  more  attends  ;  it  should 
only  be  regarded  as  a  state  which  may  be  easily  operated  on  by 
morbid  or  other  agents,  and  hence  the  proneness  of  the  system 
to  fever,  from  even  slight  causes. 

1  We  would  by  no  means  employ  blisters  to  prevent  abortion,  but  would  sug- 
gest the  propriety  of  their  trial  in  cases  where  every  thing  else  had  been  tried  in 
rain:  they  have  been  useful  in  such  cases.  I  suggested  their  employment  long 
ago,  in  Rees'  Cyclopaedia,  article  Abortion. 


192 

Dr.  Denman  conjectures,  from  the  universality  of  this  febrile  dis- 
position, that  "when  duly  regulated,  it  is  probably  intended  to 
answer  some  important  purpose  to  the  child."  He  thinks  there 
is  something  like  proof,  "by  the  blood  of  the  pregnant  woman, 
which,  independently  of  disease,  is  always  found  to  have  what  is 
called  a  sizy  appearance,  though  of  a  peculiar  kind,  and  evidently 
very  different  from  that  which  is  observed  in  cases  of  inflamma- 
tion, and  which  may  be  considered  as  a  consequence  of  some 
new  and  specific  action,"  p.  233. 

It  is  a  fact  notorious  to  almost  every  body,  that  the  blood 
drawn  from  a  pregnant  woman  exhibits  an  appearance  very 
different  from  the  blood  of  a  healthy  woman  who  is  not  preg- 
nant. This  difference  in  the  aspect  of  the  blood,  in  the  pregnant 
woman,  depends  upon  a  separation  of  the  red  globules  from  the 
coagulating  lymph;  while  no  such  change  is  observed  in  the 
other.  Dr.  Denman  declares  this  to  be  "  evidently  very  different 
from  that  which  is  observed  in  cases  of  inflammation."  This  is 
by  no  means  so  evident  to  us — the  white,  or  rather  yellowish 
coat,  observed  upon  the  surface  of  both  these  bloods,  unquestion- 
ably consists  of  the  same  material,  namely,  the  coagulating 
lymph.  The  difference  which  he  declares  to  be  so  evident,  un- 
fortunately, he  has  not  pointed  out;  and  it  certainly  remains 
to  be  proved,  that  this  coat,  in  both  instances,  is  not  owing  to  an 
alteration  produced  by  the  same  agency;  namely,  by  that  pecu- 
liar arterial  action  attending  on  both  pregnancy  and  inflamma- 
tion. 

Mr.  Hewson  first  taught  us,  that  when  this  coat  appeared  on 
the  surface  of  drawn  blood,  it  was  owing  to  the  thinning  of  the 
serous  parts  of  this  fluid,  which  enabled  the  colouring  matter 
and  other  denser  parts  of  it  to  separate,  and  precipitate  them- 
selves to  the  bottom  of  the  vessel.  That  the  density  of  this 
"coat"  may  differ  in  two  instances,  we  have  no  objection  to  ad- 
mit, since  this  \xill  not  prove  that  both  are  not  one  and  the  same 
thing;  namely,  the  coagulating  lymph.  Besides,  to  our  view, 
the  cause  of  this  peculiarity  appears  so  analogous  in  both  in- 
stances, that  we  do  not  hesitate  to  admit  them  to  be  the  same ; 
namely,  an  increased  arterial  action,  which  we  call  inflammatory, 
for  want  of  a  more  definite  term. 

We  have  already  said  that  this  condition  of  the  arterial  system 
is  so  general,  as  almost  to  force  us  to  the  belief  that  some  spe- 
cific object  is  attained  by  it — but  what  this  condition  is,  can  at 
present  only  be  conjectured. 

Dr.  Denman  supposes  it  may  contribute^  to  some  good  to  the 
child ;  but  how  this  is  effected,  he  has  not  informed  us.  We  will, 
therefore,  offer  a  conjecture  upon  this  subject.  It  seems  now 
pretty  generally  admitted,  that  the  foetus  in  utero  is  not  nourished 
by  blood  furnished  directly  by  the  mother ;  that  is,  there  are  no 


SYSTEM    DURING    PREGNANCY.  193 

continuous  vessels  from  mother  to  child ;  consequently,  the  com- 
munication between  the  two  must  be  indirect. 

The  most  probable  manner  in  which  this  indirect  mode  is  car- 
ried on,  is  that  of  Schreger,  as  published  in  his  dissertation  "  De 
Functione  Placentse  Uterinae." 

He  says,  that  "the  uterine  vessels  pour  nothing  but  serous 
fluids  into  the  spongy  tissue  of  the  placenta ;  and  that  the  uterine 
portion  of  this  mass  is  not  as  high-coloured  as  its  corresponding, 
or  foetal  portion.  And  that  the  blood  which  circulates  in  the 
uterine  vessels  of  the  mother  is  already  too  highly  charged  with 
carbon  and  other  heterogeneous  matters,  to  serve  as  nourish- 
ment for  the  foetus ;  it  therefore  only  exhales  its  serous  part, 
which  is  purer  and  more  highly  oxygenated."  Agreeably  to 
Schreger,  then,  the  placenta  performs,  as  regards  the  foetus,  the 
office  of  a  lung,  in  which  the  blood  is  revived,  and  becomes  bet- 
ter fitted  for  nourishing  the  foetus,  and  the  purposes  of  life. 

He  also  has  a  new  theory  for  the  uses  of  the  umbilical  vein. 
He  says,  "The  serous  fluid  thrown  out  by  the  uterine  arteries 
into  the  maternal  portion  of  the  placenta,  is  absorbed  by  a  set  of 
lymphatics  which  carry  it  along  the  umbilical  cord  to  the  thora- 
cic duct ;  from  thence  to  the  left  subclavian  vein ;  the  superior 
cava;  the  heart;  and  from  thence  to  the  aorta,  by  means  of  the 
arterial  canal.  From  this  artery,  after  being  mixed  with  the 
blood  and  hematose  by  the  action  of  the  vessels  through  which 
it  has  passed,  it  is  carried  to  the  umbilical  arteries,  which  return 
it  to  the  placenta.  When  it  has  arrived  here,  it  is  not  poured 
into  the  cellules  to  be  returned  to  the  mother,  but  passes  into  the 
umbilical  veins,  whose  radicals  accompany  those  of  the  umbilical 
artery.  Nevertheless,  the  lateral  pores  of  these  arteries  depo- 
sit the  fluid  which  the  foetus  could  not  elaborate,  or  which  re- 
quires to  be  again  submitted  to  the  action  of  these  organs,  before 
it  can  serve  as  nourishment." 

This  highly  probable  and  ingenious  theory  would  lead  us  to 
conjecture  that  the  excitement  in  the  arterial  system  so  invaria- 
bly produced  by  pregnancy,  is  intended  to  have  the  blood  more 
highly  oxygenated,  and,  at  the  same  time,  from  its  increase  of 
fluidity,  to  permit  the  lymph  and  serum  more  easily  to  be  sepa- 
rated from  the  other  portions  of  the  blood  in  the  maternal  por- 
tion of  the  placenta,  and  by  this  means  convey  an  additional 
quantity  of  oxygen  for  the  purposes  of  the  fcetus.  The  vermilion 
colour  of  the  blood  shows  it  is  highly  charged  with  this  substance. 

May  we  not  in  this  way  account  for  the  foetus  in  utero  being 
so  well  sustained,  while  the  mother  is  lingering  in  the  last  stage 
of  phthisis  pulmonalis  ?  And  on  the  other  hand,  explain  the  fre- 
quency of  abortion  and  premature  delivery,  in  almost  all  the  cases 
of  small  pox,  measles,  scarlet  fever,  &c.,  where  the  sanguineous 
system  is  tending  to  typhoid  action  ?  And  also  in  other  cases 
13 


194       FEBRILE    CONDITION    OF    THE    SYSTEM. 

not  of  the  exanthematous  kind,  where  this  typhoid  disposition 
prevails  ?  So  also  in  puerperal  convulsions,  where  the  paroxysms 
almost  suspend  respiration. 

This  excited  state  of  the  sanguiferous  system  must  not  always 
be  looked  upon  as  bespeaking  a  morbid  condition  of  it ;  for  were 
this  always  to  be  rigorously  enforced  and  acted  upon,  much  mis- 
chief might  be  done ;  for,  as  it  is,  women  frequently  suffer  from 
the  injudicious  use  of  the  lancet,  or  the  too  frequent  employment 
of  cathartics.  It  should  be  considered  only  as  a  disease,  when  a 
mischievous  tendency  is  perceived,  by  the  formation  of  fever ;  or 
in  local  determinations,  giving  rise  to  pain  or  other  inconvenience, 
as  headache,  giddiness,  imperfect  vision,  difficulty  of  breathing, 
pain  in  the  side,  which  is  augmented  by  breathing,  a  full,  bound- 
ing pulse,  and  a  hot  dry  skin,  and  especially,  if  these  exacerbate, 
either  in  the  evening  or  in  the  morning.  When  either  of  these 
conditions  happen,  the  system  calls  for  remedies. 

A  few  ounces  of  blood  abstracted  from  the  arm ;  a  vegetable 
diet;  and  keeping  the  bowels  open  by  any  of  the  mild  purgatives, 
will  be  found  sufficient  for  the  immediate  removal  of  this  state 
of  the  system.  If  acidity  prevail,  magnesia  will  be  the  best  pur- 
gative we  can  employ;  if  there  be  no  acidity,  pills  of  rhubarb; 
castor  oil;  Seidlitz  powders;  sulphate  of  magnesia;  or  flour  of 
sulphur,  will  be  found  best.  All  stimulating  substances  should 
be  carefully  refrained  from ;  every  kind  of  liquor  should  be  pro- 
hibited— water  alone  should  be  the  drink. 

All  fatigue  should  be  avoided;  crowded  or  heated  rooms  should 
be  shunned;  and  all  undue  exercise,  under  the  pretence  of  "wear- 
ing off  the  fever,"  should  be  forbidden. 

Dr.  Denman  is  a  strong  advocate  for  exercise  during  pregnancy, 
and  cites,  as  instances  of  its  usefulness,  the  lower  class  of  people, 
who  are  obliged  to  take  much  of  it.  We  are  always  unwilling 
to  differ  with  this  gentleman,  though  oftentimes  obliged  to  do  so, 
as  he  furnishes  so  many  opinions  from  which  we  cannot  but  dis- 
sent. The  case  before  us  is  one  of  many,  on  which  our  experi- 
ence will  not  permit  us  to  do  otherwise  than  to  differ.  For  we 
have  always  found,  that  those  women  whose  habits  of  life  did 
not,  from  their  infancy,  oblige  them  to  be  much  upon  their  feet, 
were  always  injured  by  using  much  exercise,  because  it  was 
thought  "useful  to  their  situation."  Besides  we  are  very  far 
from  thinking  that  the  lower  class  of  women  bear  the  conse- 
quence of  pregnancy,  the  fatigues  of  labour,  and  the  contingen- 
cies of  the  puerperal  state,  better  than  women  in  the  higher 
walks  of  life. 

In  this  country,  we  can  declare,  with  much  certainty,  that  a 
much  larger  proportion  of  the  labours  of  those  who  are  in  the 
humbler  conditions  of  life,  have  an  unfavourable  termination, 
than  the  same  number  of  labours  among  the  females  in  the  higher 


VOMITING    DURING    PREGNANCY. 


195 


ranks  of  society.  Besides,  all  analogy  is  against  it,  as  the  Doctor 
himself  admits,  by  declaring,  that  quadrupeds  "neglect  their 
common  pursuits,  the  gregarious  disposition  is  suspended,  and, 
if  left  to  their  own  inclinations,  gradually  lessen  their  exercise, 
as  they  advance  in  pregnancy." 

Errors  in  diet  are  almost  constantly  committed  during  preg- 
nancy, than  which,  few  things  are  more  mischievous.  We  have 
already  adverted  to  the  tendency  of  the  system  to  plethora,  during 
this  condition  of  the  female ;  on  this  account  it  cannot  fail  to  be 
injurious  to  overcharge  or  to  over-stimulate  the  stomach. 

No  one  circumstance  has  contributed  so  certainly  to  fix  this 
error,  as  the  vulgar  speculation  upon  this  subject ;  namely,  the 
necessity  the  female  is  under  to  prepare  nourishment  for  two 
beings,  at  one  and  the  same  time;  that  is,  for  herself,  and  the 
child  within  her.  She  is,  therefore,  constantly  recommended,  to 
eat  and  drink  heartily ;  and  this  she  too  often  does,  until  the  sys- 
tem is  goaded  to  fever;  and  sometimes  to  more  sudden  and 
greater  evils,  as  convulsions  or  apoplexy. 

Mrs. ,  pregnant  with  her  first  child,  complained  of  slight 

headache ;  heat  and  restlessness  at  night ;  disagreeable  taste  in  the 
mouth ;  a  furred  tongue  in  the  morning ;  loss  of  appetite,  or  rather 
disgust  to  .food,  and  constipated  bowels.  She  was  near  her 
seventh  month  of  pregnancy.  She  was  directed  to  be  bled;  to 
take  doses  of  rhubarb  and  magnesia;  to  drink  rennet- whey,  and 
use  nothing  stronger  than  water  as  drink.  In  a  few  days  she 
was  perfectly  well,  and  returned  at  once  to  her  old  habits  of  full- 
feeding.  She  soon  had  a  return  of  her  old  symptoms,  which 
were  relieved  in  the  same  manner,  as  just  stated.  After  conti- 
nuing the  moderate  plan  of  living  for  some  time  with  great  ad- 
vantage, she  was  told  she  was  very  wrong  to  live  so  abstemiously, 
as  it  would  weaken  both  her  and  her  child  so  much,  that  much 
mischief  would  follow.  She  obeyed  the  advice  of  her  ill-judging 
friend ;  the  consequence  was  convulsions ;  from  which  she  was 
saved  with  difficulty ;  but  her  child  perished. 

SECT.  II. — Of  vomiting  during  pregnancy, 

In  the  early  part  of  pregnancy,  this  effort  of  the  stomach  is 
considered  among  its  rational  signs;  and  it  seems  to  be  instituted 
for  the  purpose  of  preventing  or  subbing  plethora.  Its  advan- 
tages, however,  are  confined  to  the  eany  periods.  When  it  con- 
tinues after  quickening,  or  renews  itself  with  severity  towards  the 
latter  period  of  gestation,  its  usefulness  is  equivocal,  if  not  de- 
cidedly mischievous. 

Dr.  Denman  says,  "If  the  vomiting  should  not  be  violent,  and 
occur  only  in  the  early  part  of  the  day,  though  very  troublesome, 
it  is  so  far  from  being  detrimental,  that  it  is  generally  found  to  be 


196  VOMITING   DURING   PREGNANCY. 

serviceable,  by  exciting  a  more  vigorous  action  of  the  uterus,  by 
bringing  the  stomach  into  a  better  state,"  p.  234. 

This  appears  to  us  a  curious  kind  of  reasoning;  for,  how  vo- 
miting is  to  be  useful,  by  producing  more  vigorous  action  of  the 
uterus,  when  that  action  is  not  required,  or  would  be  certainly 
mischievous  if  excited,  we  cannot  comprehend.  Or,  how  vomit- 
ing can  bring  the  stomach  into  a  better  state  than  it  would  be, 
when  there  is  neither  a  necessity  nor  a  disposition  to  this  effect, 
is  equally  unintelligible.  That  the  efforts  of  the  stomach  may  be 
useful  in  removing  offensive  matters  from  it,  when  these  matters 
produce  nausea  or  vomiting,  we  can  readily  comprehend;  but 
this  certainly  does  not  bring  this  organ  into  a  better  state  than 
it  was  before  such  matters  had  deranged  it. 

Vomiting  we  believe  to  be  only  useful  as  it  may  reduce  or  pre- 
vent plethora ;  and  for  this  purpose  a  very  moderate  degree  of  it 
is  all  that  is  necessary.  For  this  end  is  almost  always  answered 
in  one  of  two  ways ;  first,  by  discharging  the  food  almost  imme- 
diately after  it  is  taken  down,  thus  preventing  its  digestion  by 
throwing  it  up;  secondly,  by  severe  and  distressing  nausea,  with- 
out much  vomiting,  thus  controlling  the  inordinate  actions  of  the 
system  by  this  subduing  sensation  and  by  diminishing  or  suspend- 
ing the  powers  of  digestion.  Now,  this  is  for  the  most  part  only 
useful,  as  we  have  already  said,  in  the  earlier  months  of  preg- 
nancy ;  for,  in  the  latter  months,  the  increasing  demands  o?  the 
foetus  generally  keep  down  the  disposition  to  plethora. 

But,  however  useful  the  act  of  vomiting  may  be  in  the  earlier 
periods,  it  becomes  sometimes  a  most  dangerous  disease  when 
continued  through  the  greater  part  of  the  period  of  gestation. 
We  have  seen  it  involve  the  patient  in  imminent  danger,  from  its 
indomitable  nature,  and  from  not  being  amenable  to  remedies. 

We  have  seen  several  instances  where  we  thought  it  would  be 
right  to  bring  on  premature  labour,  and  would  in  one  instance 
have  dpne  so,  had  not  this  taken  place  spontaneously,  very  soon 
after  it  had  been  determined  on.  In  such  extreme  cases,  we 
think  it  every  way  reconcileable  to  the  most  scrupulous  morality, 
to  induce  premature  delivery  for  the  preservation  of  the  mother. 
But  it  should  also  be  recommended  to  the  attending  physician, 
in  such  cases,  never  to  perform  this  operation,  unless  it  be  sanc- 
tioned by  the  result  of  consultation. 

The  sickness  commonly^ccurs  as  soon  as  the  patient  leaves 
her  bed,  and  frequently  brasses  her  for  two  or  three  succeeding 
hours.  The  matter  thrown  up  is  usually  a  sour,  tenacious  mucus ; 
at  other  times,  a  thin,  extremely  acid  water,  which  no  wand  then 
even  excoriates  the  fauces,  and  sets  "the  teeth  on  edge."  At 
other  times,  bile  accompanies  the  discharge  even  in  considerable 
quantities.  When  bile  is  thrown  from  the  stomach,  an  emetic  of 
ipecacuanha  will  frequently  be  found  useful,  and  may,  in  the 


VOMITING    DURING    PREGNANCY.  197 

•  . 

early  months,  be  given  with  safety.  For  the  most  part,  this  vo- 
miting is  attended  with  confined  bowels ;  the  appetite  is  either 
voracious,  or  nearly  destroyed ;  but  almost  always  whimsical ; 
and,  what  is  oftentimes  remarkable  at  such  times,  the  most  un- 
promising, and  apparently  preposterous  article,  will  not  only  be 
most  acceptable  to  it,  but  best  suited  to  its  wayward  humour. 

The  vomiting,  however,  rarely  proceeds  to  any  very  dangerous 
length;  and  as  rarely  requires  a  strict  medical  treatment;  a  pro 
re  nata  plan  is,  for  the  most  part,  all  that  is  required.  I  have 
found  a  glass  of  warm  water  or  chamomile  tea,  taken  so  soon  as 
nausea  is  felt,  very  frequently  abridge  the  sickness,  by  immedi- 
ately inducing  vomiting,  or  by  composing  the  disturbed  stomach. 
Should  much  acidity  prevail  at  such  times,  a  glass  of  soda  water 
will  have  a  very  good  effect:  or  what  succeeds  admirably  some- 
times, is  the  soda  in  the  following  form : — 

R.  Bi-carbon.  sodae,  3Jss. 

Pulv.  G.  Arab.      ^ij. 

O).  menthae,          gut.  iv. 

Saech.alb.  zij. 

Aq.  Seltzer.          £iv.     M. 

Of  this  a  table-spoonful  is  to  be  taken  every  hour  or  two,  as  occasion  may 
require. 

Should  the  bowels  be  in  fault  by  their  tardiness,  small  doses  of 
calcined  magnesia,  in  a  little  milk,  will  be  found  highly  useful. 
If  nausea  and  frequent  vomitings  occur  during  the  day,  and  the 
food  be  thrown  up,  the  patient  should  be  confined  to  a  table-spoon- 
ful of  milk  every  fifteen  or  twenty  minutes,  and  no  one  thing  be- 
side ;  this  rarely  fails  to  tranquillize  the  stomach,  and  enable  it 
to  take  food  with  advantage:  we  may  occasionally  add  a  spoon- 
ful of  lime  water  to  the  milk,  until  the  stomach  be  relieved. 

But  such  is  the  predominance  of  acids,  that  none  of  the  ant- 
acids is  capable  of  overcoming  it,  though  administered  with  a 
liberal,  or  even  a  daring  hand.  I  rarely  persevere  in  the  use  of 
the  alkaline  remedies,  when  I  find  that  considerable  doses  will 
scarcely  have  a  temporary  effect:  when  this  is  the  case,  I  re- 
commend the  use  of  acids,  for  the  relief  of  this  most  distressing 
state  of  the  stomach.  Both  vegetable  and  mineral  acids  have 
been  employed  by  me,  with  perhaps  about  equal  success;  but  the 
vegetable  will  merit  the  pteferance  in  general,  on  account  of  the 
teeth.  I  have,  in  several  mstances,^confined  patients,  for  days 
together,  upon  lemon  juice  and  water,  with  the  most  decided  ad- 
vantage.1 

In  two  instances  I  have  witnessed  the  best  effects  from  substi- 

1  One  lady  took  the  juice  of  a  dozen  lemons  daily,  ami  nothing  besides,  for 
many  days  together,  with  the  most  marked  advantage.  This  lady,  in  her  last 
pregnancy,  ate  large  quantities  of  ice,  with  great  comfort  to  herself— she  ate  nearly 
a  quarter  puck  a-day. 


198  VOMITING    DURING    PREGNANCY. 

• 

luting  a  glass  of  iced  water,  for  tea  or  coffee  in  the  morning,  by 
which  the  patients  were  enabled  to  retain  a  cracker  or  two  upon 
their  stomach,  which  would  not  have  been  the  case,  had  they 
taken  either  of  the  other  substances.  When  the  vomiting  is  so 
persevering  as  to  discharge  every  thing  from  the  stomach  as  fast 
as  taken  in,  the  bowels  should  be  carefully  evacuated  daily,  by 
mild  injections;  permitting  these  to  act  rather  by  their  bulk  than 
by  their  stimulus.  Should  the  pulse  be  full,  as  it  almost  always 
is  under  these  circumstances,  a  little  blood  should  be  taken  from 
the  arm  ;  more  especially  if  headache  attend.  Should  pain,  and 
a  sensation  of  burning  about  the  region,of  the  stomach  be  felt, 
much  good  is  experienced  by  the  application  of  a  few  leeches  to 
the  part,  so  as  to  abstract  five  or  six  ounces  of  blood. 

I  have  repeatedly  found  much  benefit  from  the  use  of  the  spirit 
of  turpentine  three  or  four  times  a-day,  in  twenty-drop  doses. 
This  medicine  is  very  easily  taken,  if  mixed  in  cold  water  sweet- 
ened. When  the  system  is  not  excited  to  febrile  action,  and 
where  the  stomach  rejects  every  thing  almost  as  soon  as  swal- 
lowed, I  have  often  known  a  table-spoonful  of  clove  tea1  act  most 
promptly  and  successfully. 

With  respect  to  the  diet  of  patients  so  circumstanced,  it  would 
be  in  vain  to  point  it  out ;  as  any  plan  we  could  devise  would 
scarcely  apply  to  any  two  patients — I  generally  direct  the  use  of 
such  articles  as  their  experience  has  proved  best  suited  to  their 
condition;  and,  sometimes,  it  is  truly  astonishing  to  observe  the 
waywardness  of  the  stomach  upon  such  occasions.  I  have  lately 
had  a  patient  who  could  retain  no  article,  except  Indian  meal 
cakes  baked  pretty  hard  upon  a  board — these  uniformly  kept 
down,  and  she  literally  lived  upon  them  for  weeks. 

Our  experience  of  opium  confirms,  in  a  great  measure,  the  ob- 
servations of  Dr.  Denman,  on  the  use  of  this  drug.  He  says, 
"  In  cases  of  excessive  vomiting,  opium  in  tincture  or  substance 
is  generally  given,  and  often  with  great  advantage.  Perhaps  no 
well-founded  objection  can  be  made  to  the  occasional  use  of 
opiates,  when  violent  pain,  or  any  other  urgent  symptoms  de- 
mand them.  But  I  have  persuaded  myself,  that  their  habitual 
or  very  frequent  use,  is  prejudicial  to  the  foetus,"  p.  235. 

We  think  we  have  found  the  solid  opium  newly  made  into  a 
pill,  of  at  least  two  grains,  the  best  <rform,  when  given  by  the 
mouth ;  but  the  most  decidedly  useful  mode  is  by  enemata.  An 
enema  may  consist  of  a  gin  of  lukewarm  water  and  a  tea-spoon- 
ful of  laudanum.  This  may  be  repeated  pro  re  nata. 

We  have  lately  found  the  most  prompt  advantage,  in  two  br 
three  cases  of  excessive  vomiting,  from  a  plaster  applied  over  the 

1  This  tea  is  made  by  bruising  about  twenty  cloves,  on  which  you  pour  a  half 
pint  of  boiling  water,  and  permit  it  to  stand  covered  until  cool. 


HEARTBURN  DURING  PREGNANCY.       199 

region  of  the  stomach,  composed  of  equal  parts  of  opium,  cam- 
phor, and  hard  soap,  moistened,  sufficiently  to  spread,  by  lauda- 
num. 

SECT.  III. — Heartburn  during  Pregnancy. 

This  very  distressing  symptom  is  sometimes  one  of  the  first  the 
woman  experiences  after  impregnation — at  other  times  it  does 
not  make  its  appearance  until  gestation  is  pretty  well  advanced: 
and  sometimes  is  absent  altogether.  It  is  generally  very  dis- 
tressing and  very  difficult  to  subdue.  I  have  known  large  and 
repeated  doses  of  the  alkalies  given,  with  scarcely  a  temporary 
truce  following  their  exhibition,  much  less  permanent  benefit ;  in 
consequence  of  which  I  have,  for  many  years  past,  ceased  to  urge 
them  in  large  quantities,  where  I  find  smaller  ones  produce  no 
effect.  In  such  cases  I  think  it  better  to  abandon  the  attempt  to 
neutralize  the  acid,  and  begin  with  the  use  of  the  acids,  so  soon 
as  the  other  class  of  remedies  shall  prove  useless. 

Dr.  James,  in  a  note,  (see  his  edition  of  Burns,)  makes  the 
following  remarks  upon  this  condition  of  the  stomach :  "  The  late 
much  regretted  Dr.  Young  of  Maryland,  in  his  ingenious  experi- 
ments on  the  digestive  process,  has  almost  reduced  it  to  a  cer- 
tainty, that  the  acid  which  exists  in  the  stomach  is  to  be  referred 
to  the  liquor  gastricus ;  that  it  is  the  phosphoric  acid,  and  that 
the  acidity  of  dyspeptic  and  pregnant  women,  is  owing  to  the 
morbid  quantity  of  this  acid.  Hence,  as  he  justly  remarks,  the 
superiority  of  lime  water  as  a  corrector,  from  its  great  affinity 
to  the  phosphoric  acid,"  p.  219. 

He  recommends,  from  his  own  experience,  the  formula  of  Dr. 
Sims  for  this  complaint,  viz. 

R.  Magnesiae  Ustjje,  gj. 

Aq.  Ammoniae  purse,  3J. 

Sp.  Cinnam.  giij. 

Aq.  purae,  3VSS-     M. 

Two  or  three  spoonfuls  to  be  taken  either  occasionally,  or  when 
the  symptoms  are  more  continual,  immediately  after  every  meal. 

I  have  already,  under  the  head  of  vomiting,  mentioned  the 
advantage  of  acids,  to  counteract  the  acidity  of  the  stomach,  and 
they  well  deserve  a  trial.  The  vitriolic,  or  the  citric,  may  be 
used  freely  in  such  cases ;  but  the  latter,  as  already  observed, 
merits  the  preference. 

Magnesia  and  chalk  are  in  familiar  use ;  and  in  moderate  cases 
are  every  way  competent  to  the  exigency,  especially  the  former. 
Magnesia  should  always  be  preferred  to  chalk,  except  a  looseness 
of  bowels  accompanies  this  complaint.  The  chalk  is  never  so 
pure  as  magnesia,  and  is  always  sure  to  constipate  the  bowels — 


200  SALIVATION    DURING    PREGNANCY. 

• 

sometimes  it  is  used  in  immoderate  quantities,  and  then  it  is 
always  with  decided  injury.  I  formerly  attended  a  lady  with 
several  children,  who  was  in  the  habit  of  eating  chalk  during  her 
whole  term  of  pregnancy ;  she  used  it  in  such  excessive  quanti- 
ties as  to  render  the  bowels  almost  useless.  I  have  often  known 
her  without  an  evacuation  for  ten  or  twelve  days  together,  and 
then  it  was  only  procured  by  enemata;  the  evacuations  were 
literally  chalk.  Her  calculation,  I  well  remember,  was  three 
half-pecks  for  each  pregnancy — she  became  as  white,  nearly,  as 
the  substance  itself;  and  it  eventually  destroyed  her,  by  so  de- 
ranging her  stomach,  that  it  would  retain  nothing  upon  it. 

When  heartburn  is  moderate,  it  may  be  relieved  by  soda  wa- 
ter, lime  water,  and  milk,  and  the  occasional  use  of  magnesia. 
The  operation  of  these  substances,  in  the  cure  of  an  acid  sto- 
mach, is  easily  understood;  but  the  action  of  a  few  blanched 
almonds,  or  a  few  roasted  ground  nuts,  is  not  so  easily  explained ; 
yet  both  of  these  substances  I  have  known  most  successfully  em- 
ployed where  the  complaint  was  mild.  They  should  be  taken 
from  time  to  time  as  the  acidity  may  prevail. 

Confining  the  patient  to  any  one  article  of  diet,  of  either  the 
vegetable  or  animal  kind,  is  sometimes  productive  of  great  ad- 
vantage ;  as  simple  boiled  rice,  oysters,  milk  or  cream,  or  very 
sweet  butter  and  stale  bread,  &c. 

Costiveness  is  very  common,  and  should  be  carefully  guarded 
against ;  the  diet  should  be  made  to  conform  to  this  end,  when- 
ever practicable;  where  the  stomach  will  bear  bread  or  biscuit, 
they  should  be  made  of  unbolted  flour.  The  ship  bread,  as  it  is 
called,  I  have  occasionally  found  to  answer  a  valuable  purpose — 
but  whefe  this  is  not  sufficient,  or  it  cannot  be  used,  I  have  found 
the  following  pills  of  great  advantage,  when  properly  perse- 
vered in : — 

R.  Gum  Aloes,  sue.  gss. 
Pulv.  Rhsei.          gi. 
Ol.  Caryoph.         gut.  iv. 
Sapo  Venet.          gr.  viij. 
Syr.  Ilhsui.  q.  s.    M.  f.  pil.  xxx. 

One  of  these  every  night,  or  every  other  night,  as  may  be 
found  necessary.  One  of  these  pills  is  generally  found  to  be 
sufficient ;  but  the  dose  must  be  determined  by  the  habit  of  the 
patient. 

SECT.  IV. — Of  Salivation  during  Pregnancy. 

The  sympathy  between  the  salivary  glands  and  the  impreg- 
nated uterus  is,  perhaps,  as  remarkable  as  any  that  takes  place. 
In  a  very  moderate  degree  it  may  be  considered  as  a  pretty  ge- 


SALIVATION    DURING    PREGNANCY.  201 

neral  attendant  upon  gestation ;  as  almost  all  women,  at  such 
times,  have  more  than  an  ordinary  quantity  of  saliva  secreted. 
In  this  mild  form  it  will  scarcely  require  attention ;  for  it  may 
even  pass  without  notice.  But  it  becomes  very  distressing  and 
enfeebling,  when  excessive.  It  is  almost  always  accompanied 
with  acidity  of  the  stomach,  and  constipation  of  the  bowels:  the 
fluid  discharged  from  the  mouth,  for  the  most  part,  is  perfectly 
colourless  and  transparent;  at  other  times,  it  is  more  tenacious 
and  frothy,  and  the  quantity  poured  out  is  sometimes  incredibly 
profuse.  It  almost  always  has  an  unpleasant  taste,  though  not  at- 
tended with  an  offensive  smell  ;* — it  keeps  the  stomach  in  a  state 
of  constant  irritation,  and  not  unfrequently  provokes  vomiting, 
especially  if  the  saliva  be  tenacious,  and  require  an  effort  to  dis- 
charge it.  At  night  it  is  often  very  troublesome,  interrupting 
sleep  by  the  frequency  of  the  necessity  of  opening  the  rnouth. 

If  it  continue  long,  the  woman  becomes  weak,  both  from  the 
quantity  of  fluid  poured  from  the  mouth,  as  well  as  the  inability 
to  take  and  retain  sufficient  food  upon  the  stomach.  I  have 
never  known  this  complaint  to  prove  fatal;  though  I  have  wit- 
nessed two  cases  in  which  the  patient  was  in  great  jeopardy — 
one  of  which  I  will  relate,  as  it  is  remarkable  for  the  extent  to 
which  the  salivation  ran. 

I  was  called  upon  to  prescribe  for  Mrs.  J.,  who  was  advanced 
to  the  fifth  month  of  her  pregnancy.  At  the  second  month  she 
was  attacked  by  a  profuse  salivation;  she  discharged  daily  from 
one  to  three  quarts  of  saliva;  and  was  at  the  same  time  harassed 
by  incessant  nausea,  and  frequent  vomiting:  so  irritable  was  the 
stomach  that  it  rejected,  almost  instantly,  any  thing  that  was  put 
into  it.  She  now  became  extremely  debilitated;  so  much  so,  as 
to  be  unable  to  keep  out  of  bed ;  and  when  she  did  attempt  to 
sit  up,  she  would  faint,  if  not  quickly  replaced. 

From  a  belief  that  the  affection  might  be  local,  astringent  gar- 
gles were  freely  employed,  with  marked  disadvantage.  A  large 
blister  was  next  applied  to  the  back  of  the  neck,  with  decided, 
but  transient  benefit — that  is,  the  salivary  discharge  was  less,  the 
nausea  diminished,  and  the  vomiting  less  frequent";  but  this  favour- 
able impression  was  but  of  three  or  four  days'  duration ;  for,  after 
this  time,  all  the  unpleasant  symptoms  returned  with  their  former 
severity.  An  emetic  of  ipecacuanha  was  now  exhibited,  followed 
by  a  cathartic  of  rhubarb  and  magnesia,  without  the  smallest 
benefit; — soda  water,  lime  water  and  milk,  milk  itself,  &c.,  were, 
in  turn,  unavailingly  employed.  I  now  put  my  patient  upon  a 
diet  altogether  of  animal  substances,  and  ordered  ten  drops  of 

1  Dr.  Campbell  says,  "  It  is  an  infection  of  the  salivary  glands  (which  are  some- 
times swollen  and  tender)  principally;  in  which  the  mucous  membrane  of  the 
mouth  participates  to  a  certain  extent."  The  left  parotid  was  affected  in  one 
case.  The  gums  are  neither  spongy  nor  ulcerated. 


202  PAIN    IN   THE   RIGHT    SIDE. 

laudanum  morning  and  evening,  and  fifteen  at  bed-time:  this 
plan  succeeded  most  perfectly  in  the  course  of  a. few  days;  the 
nausea  and  vomiting  ceased,  arid  the  discharge  was  reduced  to 
less  than  a  pint  per  diem ;  and,  perhaps,  tke  force  of  habit  had 
no  inconsiderable  agency  in  the  production  of  this  quantity. 
The  bowels,  during  this  plan,  were  kept  open  by  the  extract  of 
butternut  and  rhubarb,  in  the  form  of  pills.  The  lady  never 
had  any  return  of  this  complaint  in  her  subsequent  pregnancies.1 

As  a  general  plan  of  treatment  in  this  complaint,  either  when 
moderate  or  severe,  I  endeavour  to  destroy  the  acidity  of  the 
stomach  by  the  various  antacids ;  to  keep  the  bowels  free,  by  the 
frequent  use  of  magnesia;  rinsing  the  mouth  often  with  lime 
water ;  and  the  use  of  solid  animal  food ;  together  with  a  strict 
injunction  to  the  patient  to  resist  the  desire  to  discharge  the 
saliva  from  the  mouth,  as  much  as  possible. 

This  complaint,  when  moderate,  almost  always  abates,  if  it 
does  not  altogether  cease,  after  the  fifth  or  sixth  month;  but 
when  severe,  its  period  is  uncertain.  A  lady  informed  me,  that 
this  affection  continued  with  considerable  force  during  the  whole 
period  of  gestation,  in  one  of  her  pregnancies. 


SECT.  V. — Of  Pain  in  the  Right  Side  during  Pregnancy. 

A  little  after,  and  seldom  before  the  fifth  month,  the  woman  is 
sometimes  attacked  with  a  deep-seated,  and  rather  obscure  pain, 
immediately  in  the  region  of  the  liver.  It  first  begins  with  a  very 
trifling  sensation  in  this  part,  and  gradually  increases  as  gestation 
advances.  It  is  rarely  extremely  painful ;  but  is  almost  constant, 
both  day  and  night ;  and  is  especially  severe  during  the  latter. 

It  is  not  increased  by  respiration,  unless  this  be  made  very  full, 
and  then  the  pain  is  rather  more  acute  than  ordinary.  No  cough, 
as  a  necessary  attendant,  accompanies  this  complaint ;  but  if  one 
be  present,  there  is  an  augmentation  of  pain,  but  not  of  the  sud- 
den and  emba^assing  kind  which  attends  an  inflammation  of 
the  pleura,  or  peritonitis,  and  may,  therefore,  by  this  circumstance, 
be  easily  distinguished  from  this  affection,  or  an  inflammation  of 
these  membranes.  Besides,  fever  does  not  necessarily  belong  to 
this  complaint;  and  if  one  be  present,  it  may  be  considered  as 
independent  of  it;  and  may,  therefore,  most  commonly,  be  looked 
upon  as  coincident,  rather  than  as  a  necessary  consequence. 

The  woman,  with  a  view  of  relieving  this  pain,  leans  almost 
constantly  to  one  side  when  sitting;  and  if  standing,  she  may  be 
observed  frequently  to  place  her  hand  over  the  pained  part,  and 

1  For  a  similar  case,  and  of  much  interest,  see  Churchill's  Treatise  on  Dis- 
eases of  Pregnancy  and  Child-bed,  p.  75. 


PAIN   IN   THE   RIGHT   SIDE.  203 

press  it  pretty  forcibly.  She  often  seeks  relief,  by  stretching  her- 
self upwards,  and  maintaining  this  position  as  long  as  she  well 
can ;  or  until  she  finds  herself  somewhat  relieved.  She  can  lie 
upon  either  side;  but  better  on  the  left  than  on  the  right. 

A  sensation  of  heat  is  frequently  experienced  in  the  pained 
part,  at  the  time  she  may  feel  pain.  This  is  sometimes  very  dis- 
tressing ;  and  is  occasionally  very  permanent.  The  bowels  are  not 
necessarily  influenced  by  this  affection  ;  they  maintain,  most  pro- 
bably, the  condition  they  would  be  in,  were  this  pain  not  present. 

As  pains  in  the  side  are  familiarly  treated  by  blood-letting,  so 
it  is  almost  always  had  recourse  to  in  this  complaint ;  but  never, 
as  far  as  we  have  observed,  with  the  slightest  advantage.  Nor 
has  any  other  treatment  which  we  have  advised  been  more  suc- 
cessful. Leeching,  cupping,  and  blistering,  have  in  turn  been 
employed  without  benefit.  Indeed,  we  have  now  ceased  to  pre- 
scribe for  this  complaint,  unless  it  be  attended  with  some  altera- 
tion in  the  circulating  system  ;  if  this  be  disturbed,  and  the  pulse 
tense  and  frequent,  advantage  is  sometimes  experienced  from  the 
loss  of  blood,  and  gentle  purging,  as  this  pain  may  be  aggravated 
by  this  condition  of  the  system.  But  in  this  instance,  we  pre- 
scribe for  the  general  condition  of  the  system,  and  not  for  the 
local  affection — as  we  should  have  to  do  most  probably  as  much 
were  this  pain  in  the  side  not  present. 

A  woman,  with  her  first  child,  is  more  liable  to  this  affection 
than  with  the  subsequent  ones;  unless  she  carry  her  child  very 
"high,"  as  it  is  called.  After  a  woman  has  borne  several  chil- 
dren, the  anterior  obliquity  of  the  uterus  generally  prevails,  which 
frees  her  from  the  risk  of  this  complaint;  for  it  is  caused,  we 
believe,  altogether  by  the  mechanical  pressure  which  the  fundus 
of  the  uterus  makes  against  the  liver,  as  it  mounts  up  in  the  pro- 
gress of  gestation.  Our  reasons  for  thinking  that  this  is  the 
cause,  are,  1st,  because  the  woman  who  has  the  fundus  of  the 
uterus  thrown  in  advance  of  the  symphysis  pubis,  is  never  trou- 
bled with  this  complaint  so  far  as  we  have  yet  observed ;  2d,  be- 
cause it  never  commences  until  after  the  uterus  has  risen  some 
distance  out  of  the  superior  strait;  3d,  because  the  woman  who 
has  the  fundus  of  the  uterus  thrown  to  the  right  side,  is  more 
severely  afflicted,  than  if  the  right  lateral  obliquity  of  the  uterus 
did  not  exist ;  4th,  because,  after  the  eighth  month  has  passed, 
the  woman  experiences  great  relief,  if  the  uterus  sink  into  the 
pelvis,  as  it  is  wont  to  do  at  this  period;  or  undergoes  that  change 
the  women  term  "falling;"  5th,  because  this  pain  is  increased 
whenever  the  diaphragm  is  suddenly  and  powerfully  forced 
down,  as  in  coughing,  and  in  sneezing,  though  it  is  not  felt  in 
ordinary  respiration ;  6th,  because  the  pain  increases  almost  in 
proportion  to  the  development  of  the  uterus,  or  the  advancement 
of  the  fundus ;  7th,  because  the  woman  feels  less  pain  when 


204         INQUIETUDE,   &C.,   DURING   PREGNANCY. 

standing,  than  while  lying;  for  when  standing,  the  uterus  sinks  a 
little,  and  thus  diminishes  the  pressure  against  the  liver;  8th,  be- 
cause the  woman  can  relieve  herself,  by  placing  herself  in  certain 
positions;  as  leaning  to  one  side,  or  stretching  herself  upwards; 
and  lastly,  because  very  short  women  suifer  most. 

From  this  account  of  the  cause  of  the  pain  in  the  right  side,  it 
will  at  once  be  seen,  that  nothing  can  relieve  this  affection  but 
removal  of  the  fundus  of  the  uterus  from  its  contact  with  the 
liver.  It  may  be  asked,  if  this  explanation  be  true,  why  do  not 
all  women  suffer  it?  The  answer  is  easy;  all  women  have  not 
the  fundus  of  the  uterus  to  press  against  the  liver;  because  all 
have  not  the  right  lateral  obliquity ;  because  many  have  a  ten- 
dency to  the  anterior  obliquity,  after  the  third  or  fourth  child; 
and,  in  neither  of  these  instances,  does  the  fundus  press  against 
this  viscus. 

SECT.  VI. — Of  Inquietude  and  Want  of  Sleep  during  Preg- 
nancy. 

Many  women  experience  much  inquietude  towards  the  latter 
end  of  pregnancy.  This  is  so  annoying  at  times,  as  to  prevent 
sleep.  The  limbs  are  agitated  by  involuntary  contractions  of  the 
muscles,  which,  by  the  frequency  and  suddenness  of  their  motion, 
instantly  interrupt  the  sleep,  to  which  the  woman  was  at  the  mo- 
ment strongly  inclined. 

In  most  cases,  there  is  a  strong  desire  to  sleep;  but  it  cannot 
be  indulged  in,  in  consequence  of  this  particular  state  of  the  ner- 
vous system ; — this  ennui  of  the  limbs,  if  we  may  so  term  it.  We 
have  known  it  so  severe  at  times,  as  to  make  the  woman  dread 
to  lie  in  her  bed ;  for  she  is  sure,  until  near  daylight,  to  be  doomed 
to  constant  restlessness.  To  relieve  this  inquietude,  she  traverses 
the  room,  until  fatigue,  or  diminution  of  the  paroxysms,  affords 
the  long-desired  rest.  This  repeated  loss  of  sleep  does  not  sen- 
sibly impair  the  health  of  the  woman :  for,  as  Dr.  Denman  very 
correctly  observes,  "after  a  short  repose  at  the  dawn  of  day,  she 
seems  as  much  refreshed  as  after  the  most  quiet  night." 

Dr.  Denman's  method  of  treatment  does  not  by  any  means 
comport  with  his  theory  of  this  affection.  He  says,  "Perhaps 
the  confinement  of  the  air  of  the  room,  and  the  heat  of  the  bed, 
may  be  the  immediate  cause  of  this  complaint ;  but  I  have  gene- 
rally considered  them  as  arising  from  the  constant  and  strenuous 
demands  for  nourishment,  made  by  the  child  upon  the  constitu- 
tion of  the  parent ;  for  it  is  remarkable,  that  those  women  who 
suffer  most  on  this  account,  though  reduced  in  appearance,  bring 
forth  lusty  children,  and  have  easy  labours,"  p.  245. 

From  this  explanation,  and  from  what  he  afterwards  says,  it 
would  seem  that  the  foetus  makes  larger  demands  than  the  mother 
can  well  supply :  now,  were  this  so,  there  should  be  a  deficiency 


\ 


COSTIVE.NE8S   DURING    PREGNANCY.  205 

of  blood  in  the  general  system  of  the  mother ;  but  this  is  not 
the  case ;  for  the  Doctor  recommends  almost  the  only  remedies 
we  have  seen  useful  in  this  case ;  namely,  "  bleeding  in  small 
quantities,  and  the  occasional  use  of  cooling  and  laxative  medi- 
cines." Now,  is  it  not  self-evident,  that  were  a  deficiency  of 
blood  in  the  mother's  system  the  cause  of  this  inquietude,  that 
it  could  not  possibly  be  relieved,  by  diminishing,  still  more,  the 
quantity  of  blood?  We  believe,  that  this  inquietude  arises 
from  that  peculiar  irritability  of  the  nervous  system,  which 
seems  so  constantly  to  attend  upon  .a  fulness  of  the  system, 
rather  than  on  a  deficiency  of  blood.  In  proof  of  this,  the  pulse 
is  always  quickened  and  full  in  the  evening  and  during  the  night ; 
and  is  a  true  exacerbation,  or  febrile  paroxysm,  which  spends 
itself  by  morning,  and  permits  the  patient  to  sleep  at  that  time. 
Again,  bleeding,  purging,  low  diet,  cool  air,  and  cold  water,  are 
the  best  remedies  for  this  complaint. 

The  quantity  of  blood  to  be  drawn,  must  be  regulated  by  the 
fall  of  the  pulse ;  and  it  must  be  repeated  pro  re  nata.  A  mat- 
tress should  be  substituted  for  a  feather  bed,  even  in  winter ; 
the  room  should  be  well  ventilated ;  and  the  patient  should  be 
prohibited  animal  food,  suppers,  or  any  stimulating  drink.  The 
bowels  should  be  kept  gently  open.  Dr.  Denman  says,  that  "a 
glass  of  cold  water  drunk  at  bed-time,  is  not  a  contemptible 
remedy."  We  know  that  bathing  the  face  and  hands  in  cold 
water  is  an  excellent  one,  and  should  always  be  resorted  to. 

Dr.  Denman  says,  "  Preparations  of  opium  have  little  effect, 
unless  they  are  given  in  large  quantities,  and  often  repeated." 
This  is  the  very  reverse  of  our  mode  of  exhibiting  the  prepara- 
tions of  opium.  We  never  prescribe  opium  in  any  form,  unless 
the  necessity  is  very  urgent,  and  when  bleeding  and  the  other 
remedies  have  failed ;  and  when  we  do  order  it,  it  is  always  in 
small  doses.  We  prefer  the  denarcotized,  or  the  acetated  tinc- 
ture, or  black  drop,  to  any  either  form  of  opium ;  of  the  first,  we 
give  twenty  drops  at  first ;  of  the  latter,  only  ten ;  and  if  they 
do  not  tranquillize  in  two  hours,  we  direct  from  five  to  ten  drops 
more ;  believing,  if  this  quantity  does  not  succeed,  a  larger  one 
will  not:  we,  therefore,  never  urge  its  use.  A  hop  "pillow" 
has  sometimes  succeeded  admirably  well. 

After  bleeding,  &c.,  the  Liq.  Anod.  Hoffm.  answers,  for  the 
most  part,  admirably,  and  should  always  be  tried. 

SECT.  VII. — Of  Costlvcncss  during  Pregnancy. 

It  seems  that  this  condition  of  the  bowels  is  almost  sure  to  at- 
tend the  early  periods  and  the  latter  stages  of  pregnancy.  For 
the  most  part,  it  is  only  mischievous  when  excessive;  though  it 


206  COSTIVENESS   DURING   PREGNANCY. 

is  always  inconvenient.  Dr.  Denman  is  willing  to  attach  some 
importance  to  this  state  of  the  alimentary  canal ;  with  what  pro- 
priety, remains  to  be  proved.  I  am  fully  persuaded,  however, 
that  it  is  only  decidedly  injurious  when  it  exists  in  excess  :  when 
so,  I  have  known  much  trouble  to  arise  from  it,  and  sometimes 
alarm  for  the  safety  of  the  foetus. 

When  this  state  is  allowed  to  continue  beyond  two,  or  at  most 
three  days,  much  disturbance  is  sometimes  created  by  the  genera- 
tion of  flatus,  and  colicky  pains,  with  a  frequent  and  unsuccessful 
desire  to  evacuate  the  rectum.  When  permitted  to  continue  be- 
yond this  time,  it  is  sure  to  occasion  headache,  flushing  of  the  face, 
frequent  desire  to  make  water,  and  tenesmus.  The  stomach  is 
also  not  unfrequently  disturbed  by  heartburn,  sour  eructations, 
and  vomiting,  if  these  had  been  previously  suspended  ;  or  an 
increase  of  them,  if  they  had  not  ceased. 

To  those  who  may  be  occasionally  liable  to  abortion,  it  is  par- 
ticularly desirable  to  have  this  state  of  the  bowels  altered ;  as  we 
have  every  reason  to  believe  it  has,  in  a  number  of  instances, 
caused  it.  We  have  known  some  ladies  so  regardless  of  conse- 
quences, as  to  allow  this  confined  state  of  the  bowels  to  continue 
for  ten  or  twelve  days  together.  One  lady,  in  particular,  had 
reason  to  blame  costiveness  for  three  consecutive  miscarriages. 
When  she  became  pregnant  again,  she  was  put  under  my  care, 
with  a  hope  that  I  might  be  able  to  interrupt  this  unlucky  habit. 
I  learned  from  her,  that  so  soon  as  she  became  pregnant,  her 
bowels  became  so  tardy,  as  not  to  have  a  spontaneous  opening 
oftener  than  once  in  ten,  or  twelve,  or  fourteen  days.  Hitherto, 
she  had  concealed  this  condition  from  her  friends,  from  the  mere 
aversion  she  had  to  taking  medicine,  even  of  the  most  simple 
kind ;  and  honestly  confessed  she  thought  her  former  miscar- 
riages were  altogether  owing  to  this  cause ;  but  said,  she  began 
to  feel  there  would  be  a  criminal  neglect  on  her  part,  did  she 
permit  this  to  continue ;  she,  therefore,  determined  upon  changing 
this  habit;  and  was  now  willing  to  submit  to  any  plan  we  would 
think  proper  to  direct. 

She  suffered  dreadfully  from  sickness  of  stomach,  and  vomit- 
ing; severe  and  constant  headache;  palpitation  of  the  heart;  and, 
now  and  then  long-continued  syncope.  She  was  in  her  third 
month  of  pregnancy ;  and  declared  she  began  to  feel  as  she  had 
always  previously  done,  for  two  or  three  weeks  before  she  would 
miscarry ;  that  is,  she  rested  ill  at  night,  had  great  thirst,  severe 
pain  in  her  back,  together  with  considerable  leucorrhoea,  which, 
she  observed,  always  preceded  the  more  violent  symptoms.  At 
the  time  she  was  giving  me  this  information,  she  had  not  had  an 
evacuation  for  more  than  a  week.  Her  pulse  was  full,  frequent, 
and  tense ;  face  flushed,  and  skin  dry  and  hot. 

I  directed  the  loss  of  a  few  ounces  of  blood;  to  have  an  in- 


COSTIVENESS  DURING   PREGNANCY.  207 

jection  simply  of  flaxseed  tea ;  to  take  small  doses  of  castor  oil, 
at  intervals  of  two  hours,  until  it  should  operate ;  to  drink  no- 
thing but  water,  or  molasses  and  water ;  to  abstain  from  animal 
food  and  broths ;  to  use  light,  but  regular  exercise ;  to  take 
rennet-whey  freely ;  and  to  eat  no  other  bread  but  that  made  of 
unbolted  flour.  She  readily  consented  to  a  compliance,  and  as 
faithfully  performed  her  promise;  for  which  she  was  amply 
repaid,  in  the  melioration  of  all,  and  the  entire  extinction  of 
some,  of  her  more  troublesome  symptoms,  besides  carrying  her 
child  to  the  full  period. 

She  was,  however,  chiefly  indebted  to  the  brown  bread  for  the 
permanent  soluble  state  of  her  bowels;  for,  after  she  had  com- 
menced its  use,  she  had  but  very  rarely  to  aid  it  by  magnesia. 
To  women  who  are  habitually  costive,  this  bread  is  most  im- 
portant, and  should  always  be  used ;  and  though  not  always  suf- 
ficient to  do  away  the  tendency  to  constipation,  it  nevertheless 
renders  any  mild  aperient  much  more  successful. 

A  tumbler-full  of  rich  bran  tea,  sweetened  or  otherwise,  taken 
before  breakfast,  has  had  a  very  good  effect  upon  the  bowels. 
Coffee,  sweetened  with  manna,  answers  very  well ;  honey,  where 
the  stomach  will  bear  it,  is  useful.  Injections,  made  to  act  rather 
by  their  bulk  than  their  quality,  are  exceedingly  proper  in  all 
states  of  costiveness ;  but  when  it  is  excessive,  they  should  always 
be  made  to  precede  the  use  of  purgative  medicines:  we  have  seen 
much  inconvenience  arise  from  a  neglect  of  this  caution.  The 
severe  effort  which  is  always  required  to  discharge  hardened 
faeces,  is  almost  sure  to  produce  hemorrhoids. 

Mr.  Burns  says,  this  state  of  costiveness  is  "  partly  owing  to 
the  pressure  of  the  uterus  on  the  rectum,  and  partly  owing  to 
the  increased  activity  of  the  womb  producing  a  sluggish  motion 
of  the  bowels."  We  would  ask,  in  what  does  the  "increased 
activity  of  the  womb"  consist?  Is  there  an  evidence  of  such 
activity?  Is  it  not,  at  the  .period  at  which  costiveness  is  most 
common,  passive,  and  obedient  to  the  distending  forces  within  it? 
Would  not  abortion  follow  an  increased  activity  of  this  organ  ? 
for  we  see  no  way  in  which  the  uterus  ever  displays  "activity," 
but  by  contracting;  consequently,  costiveness  cannot  depend 
upon  an  "increased  activity  of  the  womb;"  for  did  it  contract 
actively,  abortion  would  almost  certainly  follow. 

This  state  of  the  bowels  depends  chiefly  upon  that  irritation 
of  the  stomach  which  gives  rise  to  either  nausea  or  vomiting; 
and  thus  diverts  or  diminishes  the  regular  or  habitual  force  of 
the  peristaltic  motion  of  the  lower  intestines.  As  a  proof  of  this, 
where  there  is  obstinate  costiveness,  m we  almost  always  see  an 
irritable  stomach.  Indeed,  Dr.  Denman  remarks,  that  "the sto- 
mach of  pregnant  women  is  often  in  such  a  state,  that  no  internal 


208  HEMORRHOIDS,    OR    PILES. 

medicines  can  be  retained,  and  we  are  obliged  to  have  recourse 
to  clysters,"  p.  239,  art.  Costiveness.  And,  farther,  we  may 
add,  that  .there  exists  between  the  rectum  and  the  stomach  a 
reciprocal  influence  of  this  kind;  for  the  inordinate  motions  of 
the  latter  are  most  successfully  allayed  by  irritating  the  former 
by  stimulating  injections. 

But,  let  the  cause  of  costiveness  be  what  it  may,  it  is  always 
important  to  guard  against  it  in  the  pregnant  woman ;  but  it 
should,  as  suggested  above,  be  by  the  gentlest  methods ;  for  sti- 
mulating or  drastic  medicines  must  be  carefully  avoided. 

For,  though  Dr.  Denman  informs  us,  that  "experience  has 
proved  that  abortion  most  frequently  happens  to  those  who  are 
subject  to  too  relaxed  a  state  of  the  bowels,"  it  does  not  prove 
that  constipation  is  either  useful  or  innocent. 

Indeed,  we  are  of  opinion  that  though  the  fact  is  precisely  as 
stated  by  Dr.  Denman,  yet  it  does  not  prove  that  diarrhosa,  in 
such  cases,  is  the  cause  of  abortion ;  on  the  contrary,  we  are 
fully  persuaded,  that  it  is  but  the  consequence  of  an  irritation  in 
the  uterus  to  cast  off  its  contents;  and  that  the  intestines,  in 
these  instances,  only  sympathize  with  this  condition  of  this  organ. 
We  may  perhaps  be  told,  as  an  evidence  that  diarrhoea  is  the 
cause  of  abortion,  that  this  accident  has  been  prevented  in  such 
cases  by  the  application  of  opium  to  the  rectum.  We  believe 
it  to  be  strictly  true,  that  abortion  has  been  prevented  by  this 
means ;  yet  we  cannot  admit  it  as  evidence  of  the  fact  insisted 
on ;  for  this  remedy  is  equally,  if  not  more  certainly  useful  in 
threatened  abortion  when  used  in  this  manner,  when  there  is  no 
diarrhoea.  It  quiets  the  irritation  of  the  uterus,  through  the 
medium  of  that  sympathy  which  is  known  to  exist  between  these 
parts;  as  the  same  sympathy  excites  the  intestines  to  looseness, 
when  the  uterus  is  the  seat  of  irritation. 


CHAPTER  XI. 


WE  have  observed  that  the  bowels  of  pregnant  women  are 
disposed  to  become. costive;  in  consequence  of  which  a  tendency 
to  piles  is  very  often  induced,  which,  if  not  early  relieved,  will 
end  in  inflammation,  and  extreme  distention,  sometimes,  of  the 
hemorrhoidal  veins.  We  may  add  to  this,  the  constant  and 
strong  pressure,  which  the  increasing  uterus  exerts  upon  the  ves- 
sels within  the  pelvis.  Another  cause  may  aid  and  confirm  the 


HEMORRHOIDS,   OR    PILES.  209 

disposition  to  hemorrhoid;  namely,  the  sedentary  habits  of  many 
women  during  gestation. 

Joined  to  all  these,  is  the  habit  many  sedentary  women  have, 
of  using  soft  cushions  to  sit  upon.  This  permits  the  vessels  to 
distend,  though  gently  compressed;  and  by  and  by  a  hemor- 
rhoidal  "fit"  is  produced.  In  others,  again,  piles  are  brought 
on  by  long  standing ;  hence  all  such  as  are  obliged  to  be  a  great 
deal  upon  their  feet  during  pregnancy,  are  much  disposed  to  this 
affection. 

'A  sensation  of  fulness  and  aching  is  first  felt  in  the  verge  of 
the  anus;  this  is  followed  by  a  slight  throbbing,  which  disposes 
the  woman  to  make  a  pressure  with  her  hand  upon  the  part ; 
swelling  in  various  degrees  soon  succeeds,  accompanied  by  more 
or  less  pain.  As  a  general  rule,  the  pain  is  in  proportion  to  the 
size  and  degree  of  inflammation  of  the  tumours  which  constitute 
the  disease,  and  the  degree  of  contraction  of  the  sphincter  ani. 

Frank  says  that  these  tumours  sometimes  acquire  a  size  equal 
to  that  of  a  goose-egg ;  the  sphincter  ani  contracting  upon  them 
produces  the  severest  suffering. — Traite  de  Medecine  Pratique. 

And  that,  in  women,  in  consequence  of  the  contiguity  of  the 
hemorrhoids  with  the  vagina,  that  they  occasion  in  this  canal  a 
heat  and  burning,  and  an  itching;  so  as  to  render  conjugal  inter- 
course painful,  and  accompanied  with  a  discharge  of  blood. — 
Traite  de  Medecine  Pratique,  torn.  3,  pp.  339,  340.  Such  cases 
we  have  never  seen;  nor  have  we  ever  witnessed  their  prevent- 
ing the  descent  of  the  head  in  the  time  of  labour  by  their  size, 
as  stated  by  the  same  author. 

We  have  said  that  the  pain  is  generally  in  proportion  to  the 
size  of  the  tumours,  and  the  degree  of  inflammation,  &c. ;  but 
this  is  not  always  so,  for  we  have  seen  prodigious  suffering  from 
small-sized  piles ;  and  once  witnessed  the  most  intense,  and  long- 
continued  anguish,  from  a  pile  not  larger  than  a  very  small  filbert. 
Why  the  pain  was  so  intense,  in  this  instance,  we  have  never 
been  able  to  account ;  it  resisted  puncturing,  leechings,  cold,  ho^ 
and  anodyne  applications,  and  purging.  A  horizontal  position, 
with  elevated  hips,  &c.,  for  several  days,  appeared  to  be  the  only 
source  of  comfort  to  the  patient. 

Dr.  Physick  informed  me,  when  speaking  on  this  subject,  that 
a  patient  of  his  suffered  the  most  intense  anguish  from  a  tumour 
not  larger  than  a  pea,  situated  in  the  verge  of  the  anus,  and  for 
which  almost  every  probable  remedy  had  been  prescribed  un- 
availingly — the  patient  was  at  last  relieved  by  the  removal  of  it 
by  the  knife. 

The  degree  of  distention  which  these  tumours  sometimes  suf- 
fer is  almost  beyond  belief.     We  have  seen  two  or  three  at  one 
time,  of  the  size  of  small  walnuts,  of  a  very  dark  red,  or  modena 
14 


210  HEMORRHOIDS,   OR    PILES. 

colour,  or  even  livid ;  and  of  such  exquisite  tenderness,  as  not 
to  permit  the  slightest  touch,  without  great  pain.1  In  these 
cases  the  sphincter  ani  acted  like  a  ligature  moderately  drawn ; 
and  the  tumours  themselves  had  the  appearance  of  strangulation. 
Indeed,  Mr.  Copeland2  considers  the  action  of  the  sphincter  ani 
one  of  the  causes  of  piles ;  especially  in  those  who  possess  this 
power  in  a  high  degree,  and  who  are,  in  consequence,  subject  to 
a  spasmodic  stricture  of  the  rectum.  In  such  persons,  he  sup- 
poses, that,  at  every  attempt  to  pass  the  feces,  a  portion  of  the 
internal  membrane  of  the  rectum,  with  its  vessels,  is  protruded 
and  detained  by  the  forcible  constriction  of  this  muscle ;  hence, 
the  formation  of  piles. 

Mr.  Burns  thinks  this  disease  is  "  chiefly  to  be  attributed  to  a 
sluggish  state  of  the  alimentary  canal,  communicating  a  similar 
torpor  to  the  hemorrhoidal  veins,"  p.  223.  Now,  we  do  not  un- 
derstand how  torpor  of  the  intestinal  tube  is  to  communicate  tor- 
por to  the  hemorrhoidal  veins ;  or  how  torpor,  any  way  communi- 
cated to  these  veins,  shall  give  the  phenomena  of  piles.  Certain 
it  is,  a  paroxysm  of  this  disease  is  as  frequently,  or,  at  least,  as 
readily  produced  by  purging,  as  by  costiveness.  For,  generally 
speaking,  the  paroxysm  of  piles  takes  place  when  costiveness  is 
about  to  be  removed,  and  not  during  the  passive  state  of  the  colon 
and  rectum.  Costiveness,  then,  as  a  sign  of  the  "sluggish  state 
of  the  intestinal  tube,"  is  rarely  the  exciting  cause  of  the  disease 
in  question ;  for  it  takes  place  with  most  certainty  when  this 
"torpor"  is  absolutely  removed,  and  the  bowels  are  stimulated 
to  brisker  action.  Therefore,  the  mechanical  pressure  of  the 
feces  may  have  some  agency  in  producing  a  "spell."3 

Besides,  it  is  familiar  to  every  body,  with  what  facility  a  "  fit " 
of  the  piles  is  brought  on  by  a  brisk  purgative,  when  the  hemor- 
rhoidal veins  are  varicose;  nor  is  this,  perhaps,  difficult  to  under- 
stand, when  we  take  into  view,  that  the  action  of  the  bowels,  and 
that  for  the  returning  of  the  blood  through  the  vessels  concerned, 
are  in  opposite  directions;  and  that  the  peristaltic  action  of  the 
colon  and  rectum  must  be  superior  to  that  of  the  hemorrhoidal 
veins ;  hence,  the  accumulation  of  blood  in  them,  and  sometimes 
their  severe  distention;  and  that  this  distention  takes  place  the 
more  readily  as  these  veins  do  not  possess  valves. 

Again,  relief  from  suffering  is  sometimes  obtained  only  by  in- 

1  The  degree  of  pain  which  attends  the  active  stage  of  piles,  depends  very  much 
upon  the  constitutional  force  of  the  sphincter  ani.  Where  this  is  very  active,  and 
constricts  the  protruded  pile  with  great  firmness,  much  suffering  will  be  endured; 
•while  an  equal,  or  even  greater  degree  of  swelling,  in  lax  and  debilitated  habits. 
will  be  attended  by  less. 

a  Observations  on  the  Principal  Diseases  of  the  Rectum,  &c.,  p.  68. 

*  Costiveness  is  not  always  necessary,  either  as  a  remote,  or  as  an  exciting 
cause  to  this  disease.  We  have  known  this  complaint  to  be  occasionally  violent, 
where  the  bowels  were  nevex  costive  for  a  day  during  a  long  life. 


HEMORRHOIDS,   OR  PILES.  211 

ducing  a  "torpor"  in  the  rectum,  by  means  of  sedative  applica- 
tions, and  opiate  injections. 

When  this  disease  attacks  the  pregnant  woman,  it  is  almost 
sure  to  produce  feverish  excitement  in  the  system ;  and  this  often 
attended  with  severe  headach,  and  pain  in  the  small  of  the  back. 
Blood-letting  is  here  clearly  indicated ;  but  the  local  is  preferable 
to  the  general  abstraction  of  blood.  Six  or  eight  ounces  of  blood 
should  be  drawn  from  the  tumours,  and  their  immediate  neigh- 
bourhood, by  leeches,  and  their  bites  encouraged  to  bleed  after 
their  dismissal,  by  the  application  of  a  soft  bread  and  milk  poul- 
tice. The  bowels  should  be  opened  by  the  most  gentle  laxa- 
tives ;  the  best  of  which,  for  immediate  purposes,  is  the  castor 
oil,  when  the  patient  may  have  no  fixed  aversion  to  it. 

If  leeches  cannot  be  procured,  puncturing  them  with  the  point 
of  a  sharp  lancet  in  several  places,  will  often  afford  great  relief, 
when  the  tumours  are  much  distended  and  very  thin.  But  when 
the  swelling  is  less,  and  the  coats  of  the  tumours  appear  thick 
and  dense,  we  do  not  recollect  to  have  seen  any  advantage  fol- 
low puncturing.  Probably  we  had  better  not  employ  it. 

Local  applications  are  rarely  found  to  be  of  benefit  during  the 
very  active  stage  of  hemorrhoids ;  indeed,  for  the  most  part,  they 
seem  but  to  aggravate  the  pain,  unless  it  be  after  leeching  or 
puncturing;  then,  as  already  directed,  a  simple  bread  and  milk 
poultice,  or  poultice  of  the  flour  of  linseed,  is  sometimes  found 
to  afford  much  relief.1  This  application  should  always  follow 
either  of  these  operations;  and  it  may  be  renewed  frequently. 

During  this  time,  the  patient  should  be  kept  in  a  horizontal 
position,  with  her  hips  elevated,  and  the  knees  drawn  up ;  and 
when  the  leech  bites,  or  the  punctures  have  ceased  to  bleed,  there 
is  sometimes  much  comfort  derived  from  cold  applications ;  even 
ice  itself.  This  is  best  managed  by  being  enclosed  in  a  small 
bladder,  in  which  there  is  some  water.  A  weak  solution  of  the 
acetate  of  lead,  that  is,  in  the  proportion  of  a  scruple  to  eight 
ounces  of  water,  and  a  few  drops  of  the  acetated  tincture  of 
opium,  sometimes  afford  much  relief. 

It  may  be  necessary  to  reapply  leeches,  or  repeat  the  punc- 
turing; this  will  especially  be  the  case,  when  the  sphincter  ani 
acts  as  a  ligature ;  for  nothing  effects  the  relaxation  of  this  mus- 
cle like  blood-letting.  The  bleeding  may  be  followed  by  the 
poultices ;  and  these  by  the  cold  applications,  or  the  saturnine 
solution  and  the  opium. 

When  the  hemorrhoidal  tumours  are  neither  very  large  nor 
very  painful,  much  advantage  is  sometimes  obtained  by  dis- 
charging the  blood  from  them  by  a  very  gentle,  but  persevering 

1  The  poultices  must  be  renewed  every  three  or  four  hours  :  they  should  be 
thin,  and  always  applied  between  very  fine  rags. 


212  HEMOURHOIDS,   OB,    PILES. 

pressure  by  the  ball  of  the  thumb,  or  extremity  of  a  finger.  This 
succeeds  best,  where  the  sphincter  ani  is  contracted  upon  the 
tumours ;  but,  in  order  to  secure  the  good  effect  of  this  pressure, 
the  pile  must  be  returned  beyond  the  verge  of  the  anus,  by  the 
finger  following  it  within  the  sphincter.  When  the  sphincter  is 
relaxed,  we  have  seen  no  advantage  derived  from  this  practice ; 
as  the  vein  prolapses  again  immediately.  To  succeed  in  putting 
up  the  pile,  much  patience  must  sometimes  be  exercised  in  making 
the  pressure ;  for,  if  it  be  done  suddenly,  much  pain  is  excited, 
and  no  advantage  gained.  Mr.  Burns  recommends,  for  the  same 
object,  a  pressure  made  by  the  thumb  and  finger. 

This  disease  is  almost  always  more  severe  after  labour  than 
during  pregnancy;  and,  though  it  is  not  strictly  a  disease  of  the 
female,  she  may  yet  be  considered  as  more  obnoxious  to  it  than 
the  male ;  and  as  it  is  an  attendant  upon  gestation,  and  is  almost 
always  a  follower  of  delivery,  it  seems  every  way  entitled  to  our 
notice. 

Much  may  be  done  during  labour  to  prevent  a  severe  "spell" 
of  piles,  by  the  accoucheur  making  a  firm  pressure  upon  the  verge 
of  the  anus  with  the  palm  of  his  hand,  guarded  by  a  diaper, 
during  the  progress  of  the  head  through  the  external  parts ;  and 
by  carefully  returning  them  immediately  after  the  expulsion  of 
the  placenta,  as  the  sphincter  is  now  fatigued,  and  will  not  op- 
pose their  ascent.  In  lying-in  women,  this  complaint  rarely 
becomes  severe  until  the  fourth  or  fifth  day ;  and  then  it  is  gene- 
rally after  the  operation  of  the  medicine  which  it  has  been  judged 
proper  to  give  previously  to  this  time. 

The  hemorrhoidal  veins  sometimes  swell  enormously  at  this 
period,  as  they  .are  probably  weakened  by  the  distention  they 
have  suffered  during  the  progress  of  labour ;  and  especially  as 
they  regain  the  power  of  contracting  with  great  difficulty.  They 
are.  however,  to  be  treated  as  above  directed ;  except  that  we 
cannot  use  the  cold  applications  with  the  same  freedom.  In  order 
to  prevent  as  much  as  possible  the  accession  of  this  disease,  with 
those  who  are  subject  to  hemorrhoids  after  delivery,  we  should 
open  the  bowels  a  day  or  two  earlier  than  is  usual;  that  is,  the 
day  but  one  after  the  termination  of  the  labour. 

This  should  be  done  by  the  very  mildest  means ;  and  small  or 
divided  closes  of  the  purgative  should  be  given,  instead  of  a  full 
dose  at  once.  Thus,  half  an  ounce  of  castor  oil  should  be  given; 
and  repeated  in  four  hours,  if  the  first  does  not  answer.  Or  coffee 
may  be  sweetened  with  manna,  and  the  patient  take  a  cup  of  it 
once  in  two  or  three  hours,  until  the  effect  is  produced.  The 
lenitive  electuary  is  also  an  excellent  aperient  at  this  time;  the 
size  of  a  nutmeg  may  be  taken  every  three  hours,  until  the  bowels 
are  stirred.  The  sulphate  of  magnesia  in  lemonade,  in  small 
doses,  is  also  very  gentle,  and  very  certain.  But  the  magnesia 


HEMORRHOIDS,     OR    PTLBS.  213 

itself,  we  think,  is  always  productive  of  much  irritation  in  the 
rectum  at  this  time.  Dr.  Jackson  of  Northumberland,  recom- 
mends, in  very  decided  terms,  rhubarb,  as  a  cathartic  in  all  stages 
of  hemorrhoidal  suffering. 

All  the  more  stimulating  cathartics  should  be  carefully  avoided ; 
and  even  the  effects  of  the  milder  ones  be  stopped  in  such  cases, 
when  they  appear  to  be  proceeding  too  far — this  may  be  readily 
effected  by  a  few  drops  of  laudanum. 

The  diet  of  the  patient  should  consist  altogether  of  the  vegeta- 
ble jellies,  rennet,  or  cremor  tartar  whey:  we  should,  for  the  time 
being,  forbid  tea  and  coffee,  unless  the  latter  is  sweetened  with 
the  manna.  Sago,  tapioca,  arrow  root,  or  gum  Arabic,  rye  mush 
and  molasses,  may  be  given  freely;  but  they  should  always  be 
made  thin ;  and  the  bran  bread  should  be  eaten.  Substances  may 
be  made  palatable  by  a  little  lemon  juice  and  sugar;  they  should 
be  looked  upon  rather  as  drinks,  than  be  considered  as  food. 
^This  plan  has  advantages  which  are  rarely  considered:  it  not 
only  affords  an  ample,  and  very  mild  nourishment,  but  the  recre- 
ment is  less  in  quantity,  as  well  as  much  less  firm  in  quality,  than 
that  from  more  solid  food.  Milk,  at  this  time,  should  be  used 
sparingly,  if  not  absolutely  forbidden,  as  the  curd  becomes  im- 
pacted in  the  rectum,  and  produces  great  irritation.  We  have 
known  much  inconvenience  to  arise  from  a  perseverance  in  this 
article  as  a  diet,  from  the  great  firmness  of  the  feces. 

The  pregnant  woman  may  derive  both  comfort  and  advantage 
from  sitting  in  a  demi-bath  of  cold  water  for  five  or  ten  minutes 
at  a  time,  two  or  three  times  a  day,  when  the  complaint  is  ad- 
vancing, or  when  about  to  retire ;  that  is,  after  the  severer  in- 
flammatory symptoms  have  abated,  or  before  they  are  high. 

During  the  progress  of  treatment,  and  for  some  time  after,  the 
patient  should  be  as  little  as  possible  upon  her  feet.  Sufficient 
attention  is  not  paid  to  this  circumstance ;  and  the  neglect  of  it 
obliges  the  woman  to  go  through  her  troubles  again.  The  ves- 
sels should  be  allowed  to  contract  as  much  as  they  are  capable 
of  doing,  before  the  woman  is  permitted  either  to  stand  or  walk 
much ;  for  the  mere  effects  of  gravitation  will  renew  the  com- 
plaint, when  it  has  but  imperfectly  receded,  or  has  but  for  a  short 
time  ceased  to  be  troublesome. 

We  have  said  purging  should  be  carefully  avoided ;  but  cos- 
tiveness  should  be  equally  shunned.  The  patient,  therefore, 
should  have  such  a  plan  laid  down,  as  will  ensure  one  liquid  eva- 
cuation per  diem ;  this  will  be  best  effected,  by  using  the  bran 
bread  constantly,  instead  of  the  common  bread,  or  sweetening 
her  food  and  drinks  with  the  flake  manna;  this  is  a  very  conveni- 
ent way  of  administering  a  gentle  purgative.  This  article,  then, 
will  form  an  exception  to  the  rule  suggested  above,  of  allowing 
no  other  than  fluid  nourishment.  And  when  all  inflammatory 


214  HEMORRHOIDS,    OR    PILES. 

action  has  ceased,  she  may  be  indulged  daily  with  chicken  water, 
or  beef  tea. 

Should  the  bran  bread  be  found  insufficient  to  keep  the  bowels 
open,  a  large  tea-spoonful  of  the  following  electuary  should  be 
taken  at  bed-time ;  either  every  night  or  oftener,  or  every  other 
night,  as  its  effects  may  be  upon  the  bowels. 

R.  Lac.  sulph. 

Crem.  tart.  aa.  ^ss. 
Syr.  commun.  vel  lemon,  q.  s. 
F.  elect. 

Dr.  Leake  is  prejudiced  against  the  use  of  sulphur  in  this  com- 
plaint ;  he  says,  "  From  what  I  have  repeatedly  seen  of  its  effects, 
I  cannot  think  favourably  of  it,  having  twice  observed  a  very 
dangerous  and  profuse  discharge  of  blood  from  the  womb,  occa- 
sioned by  its  liberal  use." — Treatise  on  Child-bed  Fever,  vol.  i. 
p.  173.  ' 

The  experience  of  Dr.  Leake,  from  its  extent,  should,  upon 
most  occasions,  go  for  much;  but  in  this  instance,  we  think  he 
has  yielded  to  a  prejudice,  resulting  from  coincidence  rather 
than  from  a  conviction  arising  from  correct  observation.  For, 
were  the  sulphur  capable  of  producing  such  discharges  as  one  of 
its  common  effects,  it  would  certainly  have  been  oftener  observed 
by  the  doctor ;  at  least  it  would  have  been  confirmed  by  the  ob- 
servations of  other  practitioners.  As  regards  ourselves,  it  is  one 
of  the  most  common  of  our  prescriptions  in  this  complaint;  yet 
we  have  never  seen  any  thing  like  the  effect  supposed  to  be  ob- 
served by  Dr.  Leake;  we  are  therefore  inclined  to  believe,  that 
the  discharges  of  blood  spoken  of,  must  have  been  accidental,  or 
coincident. 

Dr.  Good  observes  of  this  article,  "Sulphur  has  long  been  re- 
garded as  a  specific  for  piles ;  but  I  do  not  know  that  it  possesses 
any  other  virtue  than  that  of  being  a  mild  aperient.  It  seems, 
however,  to  be  an  aperient  particularly  calculated  to  act  upon 
the  large  intestines;  since,  being  soluble  with  difficulty  in  ani- 
mal fluids,  it  dissolves  slowly,  and  does  not  spend  itself  till  it  has 
descended  to  a  considerable  depth  in  the  alvine  canal.  And  it 
is  on  this  ground,  perhaps,  if  any,  that  it  sometimes  proves  ser- 
viceable in  the  present  disease." — Study  of  Med.  vol.  i.  p.  237. 

Dr.  Cullen  speaks  favourably  of  the  balsam  of  copaiva.  He 
says,  "I  have  learned,  from  an  empirical  practitioner,  that  it 
gives  relief  in  hemorrhoidal  affections,  and  I  have  frequently 
employed  it  with  success." — Mat.  Med.  part  ii.  cap.  v.  p.  190. 
Of  this  medicine  I  can  say  nothing  from  experience;  if  it  be 
useful  in  this  complaint,  it  must,  most  probably,  like  turpentine, 
be  in  cases  accompanied  by  discharges  of  blood. 

Dr.  Good  seems  to  think  differently;  and  he  may  be  right,  as 
he  has  experience  of  its  effects  on  his  side.  He  says,  "I  have 


tf      . *:• 

^  f 

HEMORRHOIDS,   OR   PILES.  215      * 

tried  this  medicine  often,  frequently  without  the  slightest  benefit, 
though  I  have  varied  the  dose ;  and  when  it  has  appeared  useful, 
it  has  been  chiefly  in  the  mucous  piles."  p.  237. 

"  Where  the  tubercles  are  not  very  sore,  they  will  often  yield 
to  a  layer  of  gypsum,  or,  what  is  better,  fuller's  earth,  which, 
however,  should  be  rubbed  into  as  soft  a  paste  as  possible.  This 
is  a  remedy  which  has  been  long  employed  on  the  continent ;  and 
I  have  sometimes  prescribed  it  with  singular  advantage,  and 
have  known  piles,  when  softish,  and  compressible,  removed  by  it 
in  a  single  night." — Study,  p.  238. 

These  excrescences  often  remain  of  considerable  size,  and  ra- 
ther painful,  even  after  the  more  active  stage  of  inflammation 
has  been  removed;  and,  if  they  be  neglected  at  this  time,  a  re- 
turn of  them  is  most  easily  provoked.  Experience  has  proved  the 
value  of  the  vegetable  astringents  for  this  purpose ;  but  they  are 
too  indiscriminately  used,  not  to  make  some  caution  necessary. 

The  astringents  are  indicated  only  in  the  decline  of  the  in- 
flammatory stage  of  this  affection,  or  after  it  has  entirely  sub- 
sided. If  used  before  this  period,  as  is  but  too  frequently  the 
case,  they  aggravate  the  complaint,  and  render  it  sometimes  very 
unmanageable ;  therefore,  the  period  at  which  they  can  be  em- 
ployed with  advantage  is  that  stated  above.  The  nutgall  has 
long  held  the  first  rank  in  the  list  of  the  vegetable  astringents ; 
and  the  following  formula  is  justly  entitled  to  much  praise  for  its 
convenience  and  efficacy: — 

R.  Gallse  Alep.  subtil,  pulv.  9j. 

Cerate  Simp.          -          ^j.  M.  adde. 
Ess.  Lemon,  -    '  1  *•         gut.  xx.  vel.  xxx. 
Acet.  Litharg.        -          gut.  xl. 
Tinct.  Thebaic,      -          gut.  xl.      M. 

A  little  of  this  ointment  is  to  be  rubbed  upon  the  parts,  morning 
and  evening.  Should  it  excite  much  smarting,  it  must  be  re- 
duced by  incorporating  a  little  more  of  the  cerate  with  it. 

At  the  stage  of  the  disease  now  spoken  of,  much  benefit  has 
occasionally  been  found  from  dusting  the  parts  with  the  flour 
of  sulphur.  Another  substance  has  gained,  in  a  certain  district 
of  this  state,  the  title  of  a  specific  in  this  complaint,  at  the  stage 
we  are  now  considering;  namely,  the  brown  powder  contained 
in  the  fungus,  commonly  called  the  "Puff  Ball,"  when  dry;  the 
dust  of  which  is  to  be  incorporated  with  hog's  lard,  and  used  in 
the  same  manner  as  the  gall  ointment. 


216  PALPITATION   OF   THE   HEART, 


CHAPTER  XII. 

OF    PALPITATION     OF    THE    HEART. 

.'-/.,..•;•     ./:.  ;i;  *  •  r,?. r •.  1 ** •< 

THIS  is  not  an  unfrequent  attendant  upon  pregnancy;  espe- 
cially before  the  period  of  quickening.  After  this  time,  it  often 
ceases,  and  does  not  return  until  towards  the  latter  part  of  the 
term  of  gestation. 

This  complaint  may  arise  from  very  different  causes :  and  it  is 
important  that  their  effects  be  not  confounded,  as  they  require 
sometimes  very  opposite  remedies  for  their  relief.1 

It  may  proceed  from  mere  nervous  irritability,  and  may  be 
looked  upon  but  as  a  symptom  of  hysteria;  to  which  some  deli- 
cate women  are  particularly  liable  during  gestation ;  or  it  may 
arise  from  fulness  of  blood,  joined  to  a  nervous  temperament,  or 
from  fulness  alone. 

In  the  first  case,  the  palpitation  will  be  attended  by  other  symp- 
toms which  mark  the  nervous  temperament,  such  as  globus  hys- 
tericus ;  large  discharges  of  limpid  urine ;  coldness  on  the  top  of 
the  head,  &c.;  and  these  may  not  be  accompanied  by  any  extra- 
ordinary fulness  of  the  circulating  system. 

Should  it  not,  we  may  administer,  with  immediate  advantage, 
almost  any  of  the  remedies  in  familiar  use  for  such  affections;  as 
the  asafoetida,  Hoffman's  anodyne  liquor,  orange  flower  water, 
hartshorn  spirit,  &c.  It  is,  however,  best,  in  all  such  cases,  to 
inquire  into  the  state  of  the  digestive  organs,  and  ascertain  if 
there  be  not  some  derangement  there,  which  may  give  rise  to  it 
— such  as  acidity  or  indigestion. 

The  first  may  be  detected  by  a  sense  of  burning  at  the  pit  of  the 
stomach,  sour  eructations,  or  belchings  tasting  like  unsound  eggs. 
If  this  be  the  case,  the  regimen  must  be  regulated,  by  forbidding 
such  substances  as  will  readily  turn  sour  upon  the  stomach ;  as 
tea,  coffee,  vegetable  substances,  fruit,  porter,  wine,  &c.,  and 
confining  the  patient  to  simple  water  as  a  drink ;  and  animal 
substances  for  food;  giving  at  the  same  time  small  doses  of  mag- 
nesia mixed  in  milk,  several  times  a  day,  if  the  bowels  be  con- 
fined; if  not,  the  extra  soda  water,  lime  water  and  milk,  aq.  am- 
mon.  purse,  &c.  If  from  indigestion,  which  is  a  frequent  cause, 
by  avoiding  such  substances  as  are  known  not  to  sit  well  upon 
the  stomach ;  by  a  dose  of  rhubarb  and  magnesia  to  carry  off  the 

'We  do  not  mean  to  extend  our  views  in  this  place  to  the  forms  of  palpita- 
tions of  the  heart  which  arise  from  organic  causes ;  but  merely  to  such  occurrences 
of  it  as  may,  with  strict  propriety,  be  called  sympathetic. 


PALPITATION    OP    THE    HEART.  217 

offensive  material,  and  confining  the  patient  for  the  next  twenty 
hours  to  chicken  water  or  beef  tea. 

If,  with  these  symptoms,  the  pulse  be  accelerated,  or  full,  and 
tense,  and  especially  if  there  be  a  throbbing  at  the  temples,  blood 
should  be  abstracted,  to  an  amount  sufficient  to  restore  the  natu- 
ral force  of  the  arterial  system.  When  this  is  accomplished,  the 
"nervous  medicines"  just  enumerated,  may  be  given  with  ad- 
vantage, if  the  bleeding  has  not  relieved  the  palpitation.  •-:*>  r 

Where  this  complaint  is  habitual  at  these  periods,  and  parti- 
cularly when  it  observes  a  pretty  regular  movement,  much  ad- 
vantage is  found  from  taking  a  small  tea-spoonful  of  the  Liq. 
Anod.  Hoffm.,  about  half  an  hour  before  it  comes  on.1  If  the 
period  of  attack  be  in  the  evening  about  bed-time,  this  remedy 
should  not  be  neglected,  as  it  will  almost  certainly  relieve  the 
sensation  and  procure  sleep. 

If  this  complaint  come  on  at  any  period  of  the  day,  or  is  pro- 
voked at  any  time  by  slight  causes,  we  have  found  much  advan- 
tage from  a  pretty  steady  use  of  the  following  tinctures : — 

R.  Tinct.  Valerian,  vol. 
Castor 

Of  this,  a  tea-spoonful  in  sweetened  water  may  be  taken  three 
or  four  times  a  day;  or  whenever  the  palpitation  is  troublesome. 
In  the  second  place,  if  palpitation  be  unaccompanied  by  nervous 
sensations;  if  there  be  headach;  flushed  face;  giddiness  of  the 
head ;  and  if  these  be  increased  upon  rising  up;  if  a  sense  of  ful- 
ness in  the  head,  with  a  feeling  of  oppression  about  the  chest ;  and 
if  sleep  be  disturbed  by  unpleasant  dreams,  we  shall  find,  almost 
always,  that  the  arterial  system  is  too  much  loaded;  the  pulse 
will  be  found  tense,  full,  or  creeping ;  irregular,  and  sluggish ; 

r  We  feel  it  a  duty  to  express  our  indignation  at  the  almost  constant  substitu- 
tion of  diluted  vitriolic  ether  for  the  valuable  article  called  Hoffman's  Anodyne 
Liquor.  This  imposition  upon  the  public  has  mainly  arisen  from  three  causes: 
1st.  On  the  part  of  the  manufacturer,  who  wishes  to  make  as  much  profit  as  pos- 
sible out  of  an  article  in  very  common  use,  the  purity  of  which,  but  too  few  me- 
dical practitioners  know  how  to  ascertain.  In  the  genuine  liquor,  there  is  an  in- 
dispensable ingredient,  called  "the  oil  of  wine,"  of  which  the  spurious  does  not 
contain  a  drop.  The  oil  of  wine  is  easily  detected,  by  mixing  a  few  drops  of  the 
liquor  with  water,  and  if  the  oil  be  present,  the  water  becomes  instantly  milky, 
as  the  oil  is  insoluble  in  water.  We  would  recommend  this  test  to  the  medical 
practitioner;  and  if  the  milky  appearance  does  not  take  place,  let  him  reject  the 
article.  2dly,  To  Mr.  Brande  having  lately  declared,  that  in  effect,  there  was  no 
difference  between  the  spurious  and  the  genuine  liquor;  than  which  there  cannot 
well  be  a  greater  error.  The  first  has  all  the  properties  of  diluted  ether — stimu- 
lating and  heating:  whereas  the  other  is  soothing  and  tranquillizing  beyond  any 
other  substance,  in  certain  cases,  with  which  we  are  acquainted.  3dly,  To  the 
parsimonious  conduct  of  the  purchaser  himself;  of  whom  the  manufacturer^ 
complains  that  he  will  not  give  the  price  for  the  genuine  article :  the  last  is  re-  ' 
prehensibly  sordid,  if  not  palpably  dishonest. 


218        OF    THE    DISPLACEMENTS    OP    THE    UTERUS. 

which  nothing  will  relieve,  but  the  loss  of  blood,  gentle  purging, 
and  an  abstemious  diet. 

Should  stimulating  remedies  be  given,  as  is  too  common,  un- 
der the  persuasion  that  weakness  is  the  cause ;  or  that  all  nervous 
affections  are  to  be  treated  by  stimuli,  much  mischief  may  ensue; 
such  as  intense  headache,  fever,  and  sometimes,  even  convulsions. 

Mr.  Burns  says,  that  "Roderic  a  Castro  prescribes  a  draught 
of  hot  water."  This  remedy,  we  have  learnt,  is  sometimes  very 
efficacious ;  it  must  be,  however,  only  when  the  stomach  is  in 
some  manner  or  other  the  cause  of  the  affection.  When  this 
complaint  is  accompanied  by  nausea  or  vomitings,  the  hot  water 
may  be  serviceable,  as  it  is  very  successful  in  allaying  gastric 
irritation. 


CHAPTER  XIII. 

OF  THE  DISPLACEMENTS  OF  THE  UTERUS. 

UNDER  this  head,  we  might  very  properly  place  every  devia- 
tion from  the  natural  position  of  this  organ.  But  to  do  this  agree- 
ably to  the  exact  meaning  of  the  words  "natural  position,"  would 
require  an  extreme  degree  of  minuteness  of  description,  as  well 
as  a  most  useless  division  of  the  different  portions  of  the  vagina. 
We  shall,  therefore,  not  consider  any  deviation  of  position  of 
this  organ,  as  coming  within  the  meaning  of  "displacement," 
that  is  not  attended  with  more  or  less  inconvenience  to  the  pa- 
tient. I  shall,  however,  confine  myself,  in  the  present  wark,  to 
the  "prolapsus  uteri,"  and  the  chronic  inversion  of  this  organ ; 
having  treated  of  the  several  other  displacements  pretty  fully  in 
my  "System  of  Midwifery." 

SECT.  I. — On  Prolapsus  of  the  Uterus. 

Notwithstanding  the  uterus  has  four  ligaments,  purporting  to 
support  and  sustain  it  in  situ,  yet  they  so  ill  perform  this  office, 
as  to  render  it  very  doubtful  whether  such  was  the  express  in- 
tention of  nature  in  their  formation — certain  it  is,  the  uterus  is 
subject  to  the  impulses  of  the  abdominal  viscera;  to  the  pressure 
of  the  distended  bladder;  and  to  the  influence  of  the  loaded  rec- 
tum and  sigmoid  flexion  of  the  colon,  and  we  might  add,  to  the 
influence  of  its  own  internal  weight  after  conception.  Besides, 
many  other  causes  may  tend  to  produce  this  displacement ;  as 
falls,  blows,  delivery,  fluor  albus,  severe  coughs,  &c. 


PROLAPSUS    OF    THE    UTERUS.  219 

Gardien1  makes  three  degrees  of  prolapsus;  namely,  1st,  re- 
laxation of  the  uterus;  2d,  descent,  or  falling  of  the  uterus;  3d, 
the  precipitation  of  the  uterus.  These  distinctions  are  not  en- 
tirely useless  in  practice ;  for  though  they  are  only  different  de- 
grees of  the  same  affection,  they  yet  require  a  little  difference 
in  the  mode  of  treatment. 

"In  the  first  degree,  the  inconveniences  arise  from  the  in- 
crease of  size  of  the  uterus;  and  are  confined  to  a  disagreeable 
dragging  towards  the  groin  and  the  umbilicus.  In  the  second 
degree,  the  woman  complains  of  a  sensation  of  weight  about  the 
fundament,  and  a  dragging  about  the  groin,  back,  and  umbili- 
cus, which  are  more  severe  than  in  the  first  degree,  and  are  aug- 
mented when  the  woman  is  on  her  feet  and  walks.  If  a  hori- 
zontal position  be  observed  for  some  time,  it  always  affords  re- 
lief; and  the  woman  every  morning  would  think  herself  cured, 
did  she  not  know,  from  experience,  all  those  symptoms  would  re- 
turn after  exercise  or  standing.  In  the  third  degree,  the  uterus 
becomes  engaged  more  or  less  in  the  os  externum,  and  sometimes 
even  escapes  from  the  vulva. 

"  In  this  case,  it  draws  the  vagina  with  it,  which  turns  upon 
itself."  "In  this  last  degree,  all  the  symptoms  just  enumerated 
are  increased ;  the  woman  feels  a  nisus,  or  bearing  down  effort 
at  the  anus  and  neck  of  the  bladder,  in  consequence  of  the  uterus 
being  engaged  in  the  external  parts,  thereby  compressing  the 
rectum  and  bladder.  But  if  the  uterus  escape  through  the  ex- 
ternal parts  the  symptoms  last  mentioned  are  less  severe,  or  are 
found  to  moderate,  when  this  takes  place ;  but  the  pain  in  the 
back,  and  the  dragging  about  the  groin,  increase,  in  consequence 
of  the  fundus  of  the  uterus  being  still  lower,"  p.  179. 

Of  the  many  casualties  to  which  the  uterus  is  liable,  the  pro- 
lapsus may  be  considered  as  the  most  frequent,  as  well  as  the 
most  troublesome,  though  not  the  most  dangerous.  This  dis- 
placement may  take  place  at  almost  any  period  of  life;  for  we 
have  witnessed  it  in  the  aged  matron,  and  have  prescribed  for  it 
in  the  youthful  virgin. 

Dr.  Campbell  (Introd.  to  the  Study  of  Mid.)  p.  445,  says, 
"  No  age,  however,  is  exempt ;  for  the  author  once  encountered 
complete  protrusion  in  a  female  of  twenty-one,  who,  it  was  said, 
laboured  under  it  for  more  than  two  years." 

Capurin  tells  us  of  a  case  of  prolapsus,  in  a  girl  of  fourteen. 
To  this  I  can  bear  witness,  from  my  own  experience ;  for  one  of 
the  most  severe  cases  of  this  kind  I  ever  witnessed  was  in  a 
girl  of  this  age.  These  are  important  facts ;  and  will  lead  to  the 
detection  (by  a  proper  examination)  of  the  cause  of  a  variety  of 
severe  symptoms,  the  origin  of  which  were  from  this  cause,  but 

1  Traite  Comp.  p.  179. 


220          PROLAPSUS  OF  THE  UTERUS. 

which  would  defy  explanation,  without  the  necessary  explora- 
tions. 

"When  we  consider  how  imperfectly  the  ligaments  attached  to 
the  uterus  sustain  it  in  situ ;  and  when  we  reflect  upon  the  fre- 
quency of  debilitating  discharges  from  the  vagina,  sapping  as 
it  were  the  very  foundation  of  its  support,  we  need  neither  be 
surprised  at  its  often  occurrence,  nor  at  the  obstinacy  of  this 
distressing  complaint.  Fluor  albus  may  be  looked  upon  as  one 
of  the  most  frequent  causes  of  prolapsus :  it  relaxes  the  vagina, 
and  makes  it  yield  to  the  weight  of  the  superincumbent  uterus, 
or  to  the  impulses  of  the  abdominal  viscera.  I  have  already  re- 
marked, that  neither  the  broad  nor  the  round  ligaments  seem 
calculated  to  sustain  the  uterus  in  its  natural  position ;  and  if 
this  be  so,  we  must  look  to  some  other  part  for  th$  support  of 
this  organ — and  this  is  the  vagina  itself.  This  office  of  the  va- 
gina may  be  deduced  from  the  manner  in  which  it  is  united  to 
the  uterus,  and  the  mode  in  which  that  canal  is  joined  to  the 
rectum  and  bladder.  The  whole  of  this  arrangement  gives  at 
once  the  idea,  that  the  vagina  is  the  efficient  support  of  the  ute- 
rus.— It  then  follows,  that  whatever  is  capable  of  weakening  the 
foundation,  will  tend  to  injure  the  superstructure ;  hence,  leucor- 
rhcea,  frequent  deliveries;1  too  early  rising  after  delivery;  very 
large  children;  a  very  large  pelvis;  habitual  coughs;  severe 
pukings,  and  ill-conducted  instrumental  deliveries,  may  all  tend 
to  this  end,  by  destroying  the  natural  tone  of  this  part,  either 
by  the  debilitating  effects  of  an  immoderate  discharge,  or  by  the 
vagina  being  overstretched ;  thus  preventing  the  return  of  its 
natural  firmness  and  resiliency;  or  by  the  frequently  repeated 
concussions  this  part  may  suffer,  from  the  abdominal  viscera,  by 
coughing  and  vomiting. 

The  degree  of  precipitation  to  which  the  uterus  may  be  liable, 
will  depend  on  the  extent  of  injury  the  vagina  may  have  sus- 
tained, from  the  causes  just  enumerated :  and  will  vary,  from  a 
slight  depression,  to  an  entire  displacement:  therefore,  in  some 
cases,  it  will  be  but  barely  within  the  os  externum. 

The  symptoms  which  characterize  this  complaint  will  be  mo- 
dified by  the  greater  or  less  descent  of  the  uterus  in  the  vagina — 
they  will  be  intense  in  proportion  (caeteris  paribus,)  to  the  ex- 
tent of  the  displacement;  but  in  all  there  will  be  a  sense  of  some- 

1  It  has  been  declared  by  Mr.  Roberton,  that  "  the  great  distention  which  the 
vagina  endures  in  giving  passage  to  the  child's  head  for  the  first  time  is  produc- 
tive of  more  temporary  injury  to  the  canal,  and  the  neighbouring  textures,  than 
happens  in  a  subsequent  delivery;  and  hence  ensues  a  condition  of  parts  favour- 
ing the  descent  of  the  uterus  and  bladder."  We  are  of  opinion  there  is  some  error 
in  this  statement,  as  it  is  a  fact  well  known  to  every  experienced  practitioner,  that 
these  parts  never  recover  their  former  condition  with  so  much  certainty  as  after 
a  first  labour. 


» 


PROLAPSUS   OF  THE   UTERUS.  221 

thing  sinking  in  the  vagina,  as  if  the  perineum  were  sustaining 
an  unusual  weight ;  with  a  dragging  sensation  about  the  hips  and 
loins;  a  desire  to  make  water,  sometimes  without  the  ability  to 
do  so ;  or  if  it  do  pass,  it  is  reluctantly,  and  oftentimes  painfully 
hot — a  sense  of  faintness,  and  occasionally  a  number  of  nervous 
or  hysterical  feelings  and  alarms,  which  almost  overwhelm  the 
patient.  A  pressure,  and  a  feeling  about  the  rectum  resembling 
a  slight  tenesmus,  sometimes  importunately  demand  the  patient's 
attention,  which,  if  she  obey,  almost  always  ends  in  unavailing 
efforts.  The  pain  in  the  back  is  sometimes  extremely  distressing 
while  the  patient  is  on  her  feet;  and  gives  to  her  walk  the  ap- 
pearance of  weakness  in  her  lower  extremities.  A  benumbing 
sensation  shoots  down  the  thighs ;  especially  when  the  woman  first 
rises  upon  her  feet ;  or  when  she  changes  this  position  for  a  hori- 
zontal one.  In  some  few  instances,  the  woman  is  obliged  to 
throw  her  body  very  much  in  advance ;  or  is  obliged  to  support 
herself  by  placing  her  hands  upon  her  thighs  when  she  attempts 
to  walk.  But  all  these  unpleasant  symptoms  subside  almost  im- 
mediately if  she  indulge  in  a  recumbent  posture,  and  this  circum- 
stance pretty  strongly  designates  the  disease. 

In  addition  to  the  inconveniences  we  have  just  stated,  there  is 
always  from  the  vagina  more  or  less  of  a  discharge  of  a  purulent 
appearance ;  this,  in  severe  cases,  is  frequently  tinged  with  blood, 
and  occasionally  is  offensive.  In  addition  to  this,  we  often  find 
the  menses  suffer  some  derangement :  they  are  almost  always 
more  abundant,  and  sometimes  more  frequent  than  they  should 
be — this,  with  the  accompanying  leucorrhoea,  very  often  reduces 
the  woman's  strength  to  a  very  low  ebb ;  and,  if  not  relieved, 
entails  upon  her  permanent  ill  health. 

In  married  women,  this  complaint,  when  excessive,  is  often 
detected  by  the  pain  that  coition  is  almost  sure  to  inflict;  and 
this  becomes  oftentimes  one  of  the  most  powerful  inducements 
with  the  female  to  apply  for  relief. 

Notwithstanding  the  diagnostics  of  a  prolapsed  uterus  are  so 
strongly  and  decidedly  marked,  yet  they  are  not  sufficiently  so 
to  warrant  us  in  taking  it  for  granted:  we  should  never,  but  fron\ 
a  careful  examination,  pronounce  this  complaint  to  be  positively 
present,  lest  we  commit  an  error,  as  once  happened  to  myself. 
I  was  consulted  by  a  lady,  who  had  long  suffered  almost  every 
symptom  recorded  above ;  I  pronounced  her  disease  to  be  a  pro- 
lapsus of  the  uterus ;  and  without  an  examination  per  vaginam, 
had  a  pessary  made  for  its  support — but,  to  my  sad  mortification, 
when  I  was  about  to  apply  it,  a  careful  examination  proved  that 
no  such  condition  existed,  and  that  all  the  unpleasant  symptoms 
had  arisen  from  a  thickening  of  the  neck  of  the  bladder. 

In  No.  II.  page  157,  of  North  Amer.  Arch.,  we  find  the  follow- 
ing denunciation  of  the  pessary,  as  a  cure  or  relief  of  prolapsus 


222  PROLAPSUS   OF   THE   UTERUS. 

uteri.  "In  such  cases,  all  the  usual  contrivances,  from  the 
simple  sponge,  up  to  the  most  complex  machinery,  -will  be  in- 
effectual, and  cannot  be  borne  by  the  patient.  Any  foreign  body 
introduced  into  the  vagina  will  give  rise  to  an  augmented  mu- 
cous secretion,  and  occasion  ulceration  and  offensive  discharges. 
On  this  account,  it  will  be  difficult  to  induce  the  individual  to 
persevere  in  the  use  of  the  instrument;  the  disease  will  continue 
to  increase,  and  will  finally  assume  a  more  formidable  character. 
This  will  be  especially  the  case,  should  the  patient  belong  to  the 
labouring  classes.  Such  individuals  cannot  maintain  the  erect 
posture  for  any  length  of  time  without  increasing  the  tendency 
of  the  organ  to  descend  :  as  they  cannot  pursue  their  avocations 
while  using  the  ordinary  instruments,  without  suffering  conside- 
rable pain,  they  are  apt  to  lay  them  aside,  and  neglect  their  con- 
dition. The  prolapsed  parts  will,  therefore,  become  ulcerated, 
and  indurated,  and  run  into  incurable  disorganization;  and 
finally,  the  constitution  of  the  patient  will  be  worn  out  and  ex- 
hausted by  fever  and  emaciation,  and  death  will  close  the  scene." 

It  will  be  naturally  asked,  what  does  Dr.  F.  himself  propose 
for  the  cure  of  this  common,  and  oftentimes  serious  evil?  We 
will  show  what  is  his  substitute  in  his  own  words,  and  let  our 
readers  draw  their  own  conclusions  of  the  merits  of  the  two 
plans. 

"All  these  difficulties  maybe  obviated  and  the  disease  effect- 
ually cured  by  episioraphy,  which  is  an  operation  instituted  with 
the  view  of  accomplishing  an  adhesion  between  the  labia,  and 
thus  securing  a  natural  barrier,  by  which  the  uterus  and  vagina 
will  be  prevented  from  prolapsing. 

"  The.  operation  is  exceedingly  simple,  and  is  performed  in  the 
following  manner.  The  patient  is  placed  upon  a  table  in  the 
same  way  as  for  the  operation  of  lithotomy,  except  that  the  hands 
and  feet  need  not  be  tied.  The  operator  seizes  one  labium  bettveen 
the  thumb  and  fingers  of  his  left  hand,  and,  with  a  sharp-pointed 
bistoury,  commences  an  incision  about  two  fingers'  breadth  below 
the  upper  commissure,  and  one  finger's  breadth  from  the  margin  of 
the  labium  itself.  This  cut  must  be  carried  by  a  bold  sweep  of  the 
knife  to  the  fourchette,  where  it  should  terminate  with  a  slight  in- 
clination inwards.  In  this  manner  a  slip  of  the  labium  will  be 
removed  of  the  breadth  of  one  finger.  By  a  similar  procedure, 
a  portion  of  the  other  labium,  of  the  same  size,  must  be  excised, 
taking  care  to  unite  the  two  incisions  about  a  finger's  breadth 
below  the  fourchette,  at  an  acute  angle,  and  include  a  portion 
of  that  frcenum.  After  securing  the  bleeding  vessels,  and 
arresting-  the  oozing  of  blood  from  the  spongy  tissue,  by 
sponging  the  part  with  cold  water,  the  lips  are  to  be  brought 
together  by  suture  in  the  common  way.  Previously  to  doing 


PROLAPSUS    OF    THE    UTERUS.  223 

this,  however,  the  operator  should  examine  carefully  the  con- 
dition of  the  vagina  and  uterus,  and  if  they  require  replacing, 
adjust  them ;  and,  to  maintain  them  in  their  situation,  introduce 
a  piece  of  soft  sponge,  previously  oiled,  and  transfixed  by  a  liga- 
ture, to  withdraw  it  when  necessary.  The  sutures  must  then  be 
drawn  close,  and  the  edges  properly  approximated  as  low  as  the 
fourchette,  which  will  generally  require  from  ten  to  twelve  liga- 
tures. The  dressings  should  be  simple,  and  secured  by  a  T 
bandage.  As  it  is  desirable  to  obtain  union  by  the  first  intention, 
and  the  contact  of  the  urine  might  prevent  it,  it  should  be  drawn 
off,  for  the  first  few  days,  by  the  catheter.  The  aperture  which 
is  left  above,  will  be  sufficient  to  give  vent  to  the  menstrual  dis- 
charge, and  the  mucus  of  the  vagina,  and  may,  even,  the  consum- 
mation of  the  venereal  act.  Should  conception  take  place,  it  will 
be  easy,  by  means  of  a  small  incision,  to  make  room  for  the  pas- 
sage of  the  child! !" 

This  horrible,  severe,  and  ill-described  operation,  is  seriously 
proposed  by  Dr.  F.  as  a  substitute  for  the  simple,  successful,  and 
easily  managed  pessary. 

We  confess  we  were  much  startled  by  the  reading  of  the  above 
serious  and  wonderfully  mischievous  effects  of  the  pessary — 
especially  as  we  have  applied  many  hundreds  of  these  instruments 
within  the  last  five  and  forty  years ;  and  in  no  one  instance  of 
this  extensive  experience,  and,  we  will  add,  careful  observation, 
have  we,  in  a  single  instance,  observed  either  of  the  mischievous 
consequences  named  by  Dr.  Frick.  If  we  have  witnessed  such 
effects,  it  must  have  arisen  from  the  bad  structure  of  the  instru- 
ment itself,  and  unskilful  mode  of  applying  it,  or  from  the  cases 
being  of  an  improper  kind  for  the  use  of  the  pessary,  and  not 
as  a  necessary  consequence  of  this  instrument,  considered  as  a 
remedial  agent  for  the  relief  of  prolapsus  uteri.  Our  experience 
has  long  since  taught  us,  that  a  well  constructed  pessary,  proper- 
ly introduced,  and  the  uterus  and  vagina  free  from  inflammation, 
scirrhus,  or  any  other  morbid  alteration  of  structure,  is  not  only 
a  safe,  but  a  highly  valuable  remedy  in  this  change  of  location, 
of  the  uterus,  and  that,  so  far  from  causing  the  evils  so  formida- 
bly presented  by  Dr.  F.,  that  it  has  proved  not  only  a  complete 
remedy  for  prolapsus,  but,  in  several  cases,  for  leucorrhoea,  that 
had  resisted  other  remedies.  For,  in  some  instances,  this  de- 
ranged position  of  the  uterus  acts  as  an  irritant  to  the  mucous 
membrane  of  the  vagina. 

A  pessary  of  proper  construction  is  the  only  efficient  remedy 
for  this  complaint — it  should  be  as  well  fitted  to  the  parts  as  the 
nature  of  things  will  permit ;  for  much  depends  upon  its  proper 
adjustment.  The  one  I  prefer  I  have  given  a  drawing  of;  it  is 
to  be  considered  but  as  a  modification  of  the  circular  elastic  gum 
pessary,  or  rather  that  of  Levret.  I  made  the  alteration  many 


224  PROLAPSUS    OF    THE    UTERUS. 

years  ago,  and  I  have  every  reason  to  be  satisfied  with  it  It  is 
formed  of  silver,  strongly  gilt ;  it  is  hollow,  and  pierced  with  a 
central  hole  of  only  sufficient  size  to  permit  the  escape  of  the  dis- 
charges incident  to  the  parts.  There  are  three  different  sizes,  one 
larger  than  the  one  of  which  a  drawing  is  given,  and  one  smaller 
— the  medium  size  is  most  frequently  required.  The  difference 
in  size  is  only  one  eighth  of  an  inch;  either  in  addition  or  in  re- 
duction. See  plate  XII. 

At  the  suggestion  of  Dr.  Hopkinson,  pessaries  of  many  sizes, 
have  been  made  of  glass,  which  have  been  found,  upon  several 
years'  experience,  to  answer,  perhaps,  even  better  than  the  gilt, 
1st.  They  are  very  much  cheaper ;  2dly.  They  are  never  acted 
upon  by  the  secretions  of  the  vagina ;  3dly.  They  are  much  more 
easily  procured.  The  only  objection  I  have  found  to  the  glass 
pessary,  is  its  extreme  smoothness — this,  however,  is  easily  ob- 
viated, by  exposing  it  to  the  action  of  the  vapour  of  the  fluoric 
acid  as  prepared  by  Dr.  Goddard. 

When  this  is  to  be  placed,  care  should  be  taken  that  the  bowels 
of  the  patient  shall  have  been  freely  opened,  and  the  urine  passed ; 
and  also,  that  she  should  have  kept  her  bed  for  an  hour  or  two 
previously  to  the  operation.  She  must  be  placed  perfectly  hori- 
zontally on  the  bed,  and  near  its  edge — the  parts  lubricated,  as 
well  as  the  instrument,  with  hog's  lard;  the  labia  must  be  sepa- 
rated by  a  couple  of  fingers ;  one  placed  on  each  labium,1  and  the 
pessary  then  pressed  gently,  but  firmly,  against  the  os  externum, 
directing  the  force  downwards  towards  the  internal  surface  of  the 
perineum,  and  backwards  in  the  direction  of  the  vagina ;  but  in 
such  a  manner  as  shall  make  the  introduced  edge  look  towards 
one  of  the  sacro-iliac  junctions.2  We  continue  to  press  the  in- 
strument forwards  in  the  course  just  pointed  out  until  the  whole 
of  it  is  received  into  the  vagina.  Then  the  finger  must  give  it 
a  transverse  direction ;  or,  in  other  words,  the  breadth  of  the  pes- 
sary must  correspond  with  the  small  diameter  of  the  inferior 
strait :  this  is  easily  effected ;  and  we  can  judge  whether  it  be 
well  placed  by  feeling  for  the  hole  in  its  centre,  which  must  al- 
ways correspond  with  the  axis  of  the  vagina. 

The  next  consideration  is  to  ascertain  whether  the  neck  of  the 
uterus  is  placed  in  the  excavation  of  the  instrument ;  (for  it  must 
be  remembered  it  should  be  introduced  so  that  its  hollow  face 
shall  look  upwards.)  This  may  be  known  by  passing  the  finger 
over  the  edge  which  is  under  the  symphysis  pubis  and  depress- 
ing it  a  little;  the  finger  will  then  readily  detect  the  position  of 
the  neck  of  the  uterus ;  and  should  it  not  be  found  in  the  centre 

1  It  is  generally  best  to  use  the  left  hand  for  this  purpose.     See  note  following. 

*  It  will  generally  be  found  most  convenient  for  the  operator  to  have  the  right 
side  of  his  patient  next  to  him;  as,  in  this  position,  he  will  command  the  intro- 
duction of  the  pessary  with  his  right  hand. 


PROLAPSUS    OF    THE    UTERUS.  225 

of  the  pessary,  it  can  readily  be  drawn  there  by  the  extremity  of 
the  finger.  When  this  is  adjusted,  we  take  care  that  the  trans- 
verse position  of  the  instrument  be  exact,  before  we  withdraw  the 
finger :  the  woman  may  now  be  permitted  to  get  up.1 

The  proper  size  of  the  instrument  is  a  matter  of  considerable 
consequence ;  and  we  cannot  always  determine,  a  priori,  which  of 
the  sizes  will  answer  best — if  it  be  too  large,  it  will  give  pain ; 
and  if  too  small,  it  will  escape,  perhaps,  on  the  first  effort  to  go 
to  stool.  We  can  ascertain  when  too  large,  by  its  producing 
much  uneasiness  in  the  parts,  and  by  the  difficulty  of  introducing 
it:  should  this  happen,  it  must  be  removed,  and  one  of  a  smaller 
size  introduced.  And  for  fear  the  instrument  be  too  small,  we 
should  direct  the  patient  not  to  go  to  the  privy,  for  a  day  or  two, 
lest  it  escape  from  her  and  be  lost. 

The  relief  afforded  by  the  introduction  of  the  pessary,  in  many 
instances,  is  immediate ;  but,  if  not,  it  is  almost  always  secured, 
in  a  short  time,  if  the  instrument  be  of  a  proper  size,  and  well 
adjusted.  It  may  be  proper  to  remark,  that  the  pessary  will  do 
no  good  where  the  perineum  has  been  destroyed  by  laceration. 
,  Before  I  employ  the  pessary,  I  almost  always,  if  there  be 
much  leucorrhoea,  but  not  otherwise,  and  when  the  time  can  be 
commanded,  make  use  of  astringent  injections  for  two  or  three 
weeks,  with  very  decided  advantage — the  best,  perhaps,  is  a  so- 
lution of  alum  in  the  proportion  of  a  half  ounce  to  a  pint  of  wa- 
ter ;  and  after  the  instrument  is  adjusted,  a  few  syringes  full  of 
fine  soap  and  water  should  be  thrown  up  the  vagina  daily — if 
the  gilt  pessary  be  employed,  it  will  need  removal  but  very 
rarely ;  not  oftener  than  once  in  two  or  perhaps  three  months ; 2 
this  gives  a  very  decided  advantage  over  every  other.  The 
period  it  must  be  worn  must'  necessarily  depend  upon,  1st.  The 
inveteracy  of  the  disease ;  2d.  The  extent  of  the  displacement ; 
3d.  The  employment  of  the  patient ;  4th.  The  greater  or  less 
disposition  to  fluor  albus.  As  a  general  rule  with  young  women, 
where  the  complaint  has  not  been  of  long  standing,  from  three  to 
four  months  will  sometimes  be  sufficient — it  will,  of  course,  require 
a  longer  time  where  the  woman  is  more  aged,  and  where  the 
complaint  is  of  long  standing — one  of  my  patients  wore  the  in- 

1  In  some  instances  we  have  found  it  best  to  confine  the  patient  to  a  horizontal 
position  for  three  or  four  days,  with  the  intention  of  giving  the  pessary  an  oppor- 
tunity of  bedding  itself  in  the  vagina.  This  is  particularly  necessary  where  there 
is  much  sensibility  in  the  parts,  or  where  the  instrument  causes  a  little  uneasiness 
after  its  introduction,  though  it  fits  the  passage  well. 

"  Indeed,  it  is  not  always  necessary  to  remove  it  so  often:  we  have  had  many 
patients  who  have  worn  the  gilt  pessary  for  six  months,  and  sometimes  even  longer, 
without  having  it  removed.  This  is  fortunate  for  the  patient,  as  it  spares  much 
moral  pain.  And  the  glass  one  can  be  worn  even  longer,  without  any  disadvau- 
tage. 

15 


226  PROLAPSUS    OF    THE    UTERUS. 

strument  a  year;  but  this  was  the  longest  time  I  have  known  it 
to  be  required.1 

Besides  the  inconveniences  just  related,  this  condition  of  the 
uterus  gives  rise  to  a  fixed  pain  in  one  of  the  sides,  but  especially 
the  left,  which  bids  defiance  to  all  general  as  well  as  local  appli- 
cations hitherto  employed  for  its' removal. 

Larrey,  the  celebrated  French  surgeon,  proposes  a  very  differ- 
ent pathology  of  this  complaint  as  well  as  mode  of  treatment. 
He  says,  it  is  owing  to  two  causes,  either  an  asthenic  (debilitated) 
thickening  of  the  uterine  parietes,  or  an  elongation  of  the  liga- 
ments, and  proposes  for  its  cure  that  the  loins,  groin,  and  other 
adjacent  parts,  should  be  cupped.  After  this,  he  applies  a  moxa 
to  each  cupped  spot,  and  this  may  be  safely  repeated;  this  to  be 
aided  by  a  horizontal  posture,  elevation  of  the  pelvis,  and  flexion 
of  the  lower  extremities;  cold  astringent  applications  and  in- 
jections, lavements,  and  a  mild,  nutritious  diet.  He  affirms  he 
has  made  permanent  cures  in  this  way. 

In  the  complaint  now  alluded  to,  and  which  we  shall  exemplify 
by  cases,  no  suspicion  was  entertained  by  the  practitioners,  who 
previously  had  had  the  care  of  them,  that  it  depended  upon  the 
prolapsed  condition  of  the  womb ;  and  it  is  but  a  few  years  since 
I  was  myself  aware  of  it.  But,  as  this  complaint  is  more  com- 
mon than  is  generally  suspected,  and  as  it  cannot  be  removed,  so 
far  as  I  know,  but  by  the  use  of  the  pessary;  and,  especially,  as 
I  have,  since  the  publication  of  the  cases  about  to  follow,  received 
various  communications  and  thanks  for  their  promulgation,  I 
have  thought  it  proper  to  detail  them  in  this  place,  that  the  at- 
tention of  practitioners  might  be  directed  to  its  consideration. 

CASE  I.  Mrs.  T.,  aged  thirty-six  years,  applied  for  my  advice, 
for  a  severe  pain  in  the  left  side,  immediately  under  the  margin 
of  the  false  ribs,  extending  to  the  spine  of  the  ileum  of  the  same 
side.  She  informed  me  she  had  had  this  for  several  years,  with 
more  or  less  severity,  and  for  which  she  had  undergone  severe 
medical  treatment,  such  as  bleeding,  purging,  blistering,  leeching, 
&c.,  without  the  slightest  benefit.  The  pain  was  not  increased 
by  respiration,  pressure,  or  motion,  but  some  relief  was  constantly 
experienced  upon  lying  down,  and  especially  as  the  night  ad- 
vanced. She  could  lie  in  any  position  without  any  increase  of 
inconvenience,  but  felt  most  comfortable  in  a  bent  posture. 

I  prescribed  for  her  a  variety  of  medicines,  with  no  better  suc- 

1  Since  writing  the  above,  I  have  found  several  patients  extremely  reluctant  to 
part  with  the  pessary  after  there  was  every  reason  to  believe  it  might  have  been 
removed  without  any  inconvenience  following.  Two  others  have  had  the  pes- 
sary restored,  declaring  they  felt  so  much  more  secure  with  it — but  none  have 
complained  of  pain,  after  the  few  first  days,  however  long  retained.  In  two  or 
three  other  instances,  they  have  been  removed  at  the  seventh  month  of  pregnancy, 
being  no  longer  of  any  use  as  a  support  to  the  uterus.  These  cases  show  that 
impregnation  takes  place,  notwithstanding  the  presence  of  the  pessary. 


PROLAPSUS   OF    THE   UTEKUS.  227 

cess  than  those  who  had  preceded  me ;  and  began  seriously  to 
despair  of  being  in  any  way  useful  to  her,  when,  thinking  the 
leucorrhoea,  with  which  she  was  severely  afflicted,  might  iiave 
some  agency  in  weakening  her,  and  believing  this,  from  the  de- 
scription of  her  feelings,  to  arise  from  a  prolapsed  uterus,  I  men- 
tioned my  suspicions  to  her,  and  stated  the  propriety  of  an  exa- 
mination to  ascertain  the  fact.  To  this  she  submitted ;  and  the 
uterus  was  found  low  in  the  vagina, 

I  ordered  her  astringent  injections,  which  were  persevered  in 
for  three  weeks,  with  as  much  advantage  as  I  had  contemplated 
-—for  the  only  benefit  I  expected  from  them  was  to  giv6-  a  tem- 
porary tone  to  the  vagina  before  I  should  introduce  a  pessary. 
At  the  end  of  three  weeks,  I  introduced  a  gilt  pessary,  and  de- 
sired my  patient  to  place  herself  upon  her  feet — this  she  did,  and 
declared  she  felt  much  more  comfortable  than  she  was  wont  to 
do  when  she  arose  from  her  bed;  and  observed,  that  for  the  first 
time  for  several  years,  she  was  free  from  the  pain  in  her  side. 
Believing  this  to  be  accidental,  I  paid  but  little  attention  to  the 
declaration  at  the  moment — but  upon  my  visiting  her  the  next 
day,  she  assured  me  she  had  no  return  of  it  whatever,  nor  has 
she  had  to  this  moment. 

This  case  made  a  strong  impression  upon  me;  especially  as  I 
could  call  to  mind  several  similar  instances  of  affections  of  the 
side,  in  which  I  had  failed  to  give  relief;  and  it  made  me  deter- 
mine, should  another  case  of  painful  side  occur,  to  inquire  imme- 
diately into  the  state  of  the  uterus.  It  was  not  long  before  this 
opportunity  presented  itself  in  a  lady  from  the  West  Indies. 

CASE  II.  Mrs.  D.  had,  for  several  years,  (five,)  been  much  af- 
flicted by  a  train  of  severe  nervous  affections — she  would,  fre- 
quently, from  the  slightest  causes,  be  thrown  into  violent  hyste- 
rical paroxysms,  which  required  considerable  time  to  calm.  She 
had  a  fixed  pain  in  the  left  side,  which  would  occasionally  appear 
to  swell,  and  become  extremely  painful  to  the  touch — when  this 
took  place,  she  was  almost  certain  that  hysteria  would  follow. 
Her  appetite  was  good,  but  her  stomach  could  only  digest  certain 
articles — her  bowels  were  constipated,  and  she  had  a  profuse 
leucorrhoea  of  a  purulent  appearance.  She  was  considerably 
reduced  in  flesh,  and  much  debilitated. 

She  had  tried  a  variety  of  remedies  in  the  West  Indies  for  the 
local  affection  of  the  side — she  had  been  repeatedly  bled  and 
blistered,  without  the  smallest  advantage — took  mercury  to  a 
considerable  extent — was  freely  purged  and  puked — but  to  no 
purpose.  When  the  pain  was  unusually  severe,  it  was  considered 
as  spasm  of  the  stomach.  From  the  detail  of  her  symptoms,  I 
was  led,  however,  to  suspect  a  prolapsus  of  the  uterus,  and  in- 
quired whether  that  opinion  had  been  given  by  her  physicians  at 
home — but  she  said  it  never  had  been  suggested;  it  was  consi- 


228          PROLAPSUS  OF  THE  UTERUS. 

dered  as  -an  affection  of  the  stomach  altogether,  and  all  remedies 
were  addressed  to  it,  either  directly  or  indirectly. 

I  proposed  an  examination  per  vaginam,  to  which  she  very 
reluctantly  consented — but  that  examination  confirmed  my  first 
suspicion  of  her  case.  I  ordered  her  the  tincture  of  cantharides, 
and  some  astringent  injections — also,  small  but  daily  doses  of 
rhubarb ;  and  continued  this  plan  for  nearly  three  weeks.  At  the 
end  of  this  time  I  placed  the  pessary.  She  was  almost  instantly 
relieved  from  the  usual  symptoms  attending  a  prolapsed  uterus, 
and  also  the  afflicting  pain  in  her  side. 

Experiencing  such  immediate  relief,  and  the  almost  total  ex- 
emption from  her  nervous  feelings,  she  became  careless,  and  al- 
lowed her  bowels  to  become,  as  they  were  wont  to  do,  exces- 
sively costive ;  and  in  an  effort  to  relieve  herself,  she  discharged 
the  pessary.  This  accident  she  concealed  from  her  friends,  until 
a  recurrent  of  all  her  former  inconveniences  and  pain,  forced 
her  to  a  confession.  I  was  immediately  sent  for,  and  the  loss  of 
the  pessary  was  made  known  to  me.  I  placed  another,  and  she 
again  was  restored  to  comfort :  and  now  is  in  the  most  perfect 
health.  She  is  no  longer  troubled  with  hysteria — palpitation  of 
the  heart — or  any  of  her  former  nervous  sensations.  She  can 
eat  without  selection,  and  her  bowels  are  perfectly  regular;  and 
we  may  now  add,  that  she  has  borne  two  children  since. 

CASE  III.  I  was  requested  to  visit  Mrs.  P.,  who  was  repre- 
sented to  be  suffering  very  much  from  an  habitual  colic.  Not 
being  well,  my  friend,  Dr.  Knight,  kindly  visited  her  for  me,  and 
prescribed  a  dose  of  laudanum,  &c.,  which  procured  her  a  tolera- 
bly good  night's  rest.  I  saw  her  the  next  morning,  and  found 
her  labouring  under  the  distressing  after-effects  of  the  laudanum, 
but  comparatively  easy.  She  gave  the  following  history  of  her 
complaint.  She  was  attacked  about  twelve  years  before  with  a 
pain  in  her  left  side,  which  was  occasionally  so  severe  as  to  pro- 
duce hysteria,  and  other  disagreeable  nervous  affections.  The 
pain  was  not  augmented  by 'pressure,  cough,  or  respiration.  She 
would  swell  sometimes  very  suddenly,  and  when  this  happened 
the  pain  was  increased.  She  was  much  incommoded  by  exercise, 
or  much  standing,  and  if  either  were  continued  too  long,  it  would 
occasion  faintness,  and  a  great  deal  of  pain.  When  this  took 
place,  she  would  be  obliged  to  go  to  bed,  take  laudanum,  and  be 
unable  to  rise  for  several  days.  She  had  leucorrhoea  to  a  great 
extent — was  much  debilitated — extremely  pale — her  appetite 
feeble — and  her  digestion  bad. 

She  was  much  afflicted  with  headache,  and  pain  in  her  back — 
also  with  a  severe  numbness  down  the  thighs,  after  standing 
awhile  upon  her  feet.  She  had  tried  a  great  many  remedies  for 
the  period  above  stated,  and  she  considered  herself  growing 
worse  daily. 


PROLAPSUS  OF  THE  UTERUS.          229 

Suspecting  a  prolapsus  of  the  uterus  to  be  the  cause  of  her 
complaints,  I  proposed  to  ascertain  it,  to  which  she  readily  con- 
sented. The  uterus  was  found  very  low ;  the  os  uteri  could  be 
felt  just  within  the  labia.  I  procured  a  pessary,  and  introduced 
it  immediately,  without  any  previous  preparation,  as  she  was 
obliged  to  go  to  New  York,  her  place  of  abode,  the  next  day. 
She  was  instantly  relieved  by  the  pessary;  and  declared  herself, 
in  five  minutes  after  its  application,  to  be  perfectly  free  from  all 
pain  and  inconvenience,  and  is  now  in  perfect  health. 

CASE  IV.  Mrs.  L.,  a  very  delicate  woman,  aged  twenty-eight, 
after  a  premature  labour,  attended  with  a  great  expenditure  of 
blood,  was  attacked  with  a  severe  cough,  which  seemed  to 
threaten  phthisis.  She  was,  however,  relieved  of  the  cough,  by 
a  persevering  use  of  remedies,  and  change  of  air ;  but  there  re- 
mained a  fixed  pain  in  the  left  side ;  a  sense  of  bearing  down  in 
the  pelvis,  and  a  strong  desire  to  make  water,  whenever  she 
stood  upon  her  feet.  I  was  convinced  she  laboured  under  a  pro- 
lapsus, and  mentioned  this  opinion  to  her  friends.  She  would 
not,  however,  submit  to  having  it  tested,  but  permitted  an  old 
nurse  to  prescribe  leeching  to  her  side,  followed  by  blistering: 
as  she  experienced  no  advantage  from  these  remedies,  she  was 
at  length  prevailed  upon  to  allow  an  examination  per  vaginam. 

I  was  accordingly  requested  to  visit  her  again,  and  to  make 
the  proposed  search — this  proved  the  uterus  prolapsed.  After 
due  preparation,  as  above  suggested,  I  applied  a  pessary,  and  she 
was  immediately  relieved,  and  continues  well  to  this  moment. 

These  cases  most  satisfactorily  prove  that  the  consequences 
of  a  prolapsed  uterus  are  sometimes  more  extensive  and  severe 
than  have  hitherto  been  suspected;  and  also  teach  us,  under 
circumstances  like  those  detailed  above,  to  make  the  necessary 
inquiries  into  the  condition  of  the  uterus.  I  will  not  pretend  to 
account  for  the  pain  in  the  left  side  when  it  occurs  there,  for  it 
is  not  invariably  the  seat  of  this  sympathetic  affection,  though 
certainly  the  most  frequent :  it  has  prevailed  in  four  consecutive 
cases ;  but  these  should  not  by  any  means  be  considered  as  suf- 
ficient to  establish  a  rule.1 

Since  the  above  cases  were  published,  a  number  of  similar 
ones  have  occurred,  of  greater  or  less  severity,  all  of  which  have 
been  relieved  by  the  same  means.  In  one  instance,  a  complete 
retention  of  urine  attended;  and  so  permanent  was  it,  and  so 
often  repeated,  that  the  husband  was  under  the  necessity  of 
learning  the  mode  of  introducing  the  catheter,  that  he  might 
give  immediate  assistance.  The  relief  afforded  by  the  pessary 
was  instantaneous  and  effectual. 

1  I  think  it  probable,  that  the  seat  of  the  painful  affection  of  the  left  side  is  in 
the  spleen ;  as  this  viscus  is  known  to  sympathize  largely  with  the  uterus. 


230          PROLAPSUS  OF  THE  UTERUS. 

The  circular  form  of  the  pessary  I  employ  I  find  answers  per- 
fectly well,  as  regards  its  mechanical  properties;  it  does  not 
press  too  violently  upon  the  neck  of  the  bladder,  or  rectum.  All 
that  is  essential  to  be  observed,  is  its  size ;  it  should  be  neither 
too  large,  nor  too  small.  Many  have  preferred  the  oval  pessary : 
thinking  it  allowed  more  room  for  the  neck  of  the  bladder,  and: 
for  the  occasional  distention  of  the  rectum.  But  as  we  have 
never  witnessed  any  advantage  to  arise  from  this  shape,  as  re- 
gards the  objects  just  stated;  and  as  the  small  ends  of  the  oval 
instrument  are  more  easily  acted  upon  than  the  circular,  and  in 
consequence  more  easily  displaced,  we  give,  after  many  trials, 
the  preference  to  the  circular  form.  Gardien  says,  "Le  pes- 
saire  de  forme  ronde  est  plus  facile  a  placer :  il  est  en  outre 
moins  sujet  &  sortir,"  p.  183. 

Gardien  speaks  of  replacing  the  uterus  in  the  first  and  second 
degree,  by  means  of  the  finger  introduced  into  the  vagina,  and 
pushing  up  this  organ ;  and  then  confining  the  woman  for  some 
time  to  a  horizontal  position  ;  and  after  all  fear  of  inflammation 
has  passed,  to  throw  up  cold  astringent  injections  into  the  va- 
gina; and  lays  some  stress  upon  the  efficacy  of  sulphur  waters 
for  this  purpose. 

Of  this  plan  we  can  say  nothing  satisfactory  from  our  own 
experience;  it  may  succeed  in  certain  recent  cases,  but  must  be 
totally  inadequate  to  relieve  a  prolapsus  of  long  standing.  He 
objects  to  the  use  of  pessaries,  until  every  other  means  has  been 
tried;  and  appears  to  entertain  many  apprehensions  of  the  action 
of  these  instruments,  which  we  are  certain,  from  long  experience, 
are  ill-founded,  provided  they  are  properly  constructed,  judi- 
ciously used,  and  not  employed  when  it  is  an. "irritable  womb" 
that  is  down.  See  art.  "Of  the  Irritable  Uterus." 

In  some  eases,  a  subsequent  pregnancy  and  delivery  have 
cured  a  moderate  prolapsus.  .We  have,  in  a  number  of  instances, 
recommended  this  mode  of  cure,  and  sometimes  it  has  succeeded 
perfectly.  To  succeed  by  this  plan,  however,  requires  a  long 
perseverance;  to  which  patients,  in  general,  will  not  submit,  how- 
ever strongly  we  may  urge  its  importance.  This  method  re- 
quires an  almost  exclusive  confinement  to  a  horizontal  position 
after  delivery,  for  six  or  eight  weeks,  (Gardien  says  four  or  five ; 
but  we  have  never  seen  so  short  a  confinement  succeed.)  The 
woman  must  be  careful  how  she  passes  her  water,  or  voids  per 
anum;  that  is,  she  must  not  strain  or  make  strong  efforts  for 
these  purposes. 


.*" 

CHRONIC    INVERSION    OF    THE    UTERUS.  231 

SECT.  II. — Of  the  Chronic  Inversion  of  the  Uterus.1 

We  shall,  in  the  present  work,  confine  ourselves  to  treating  of 
the  Chronic  Inversion  of  the  Uterus;  or  that  condition  in  which 
it  remains  after  its  complete  inversion,  where  it  was  impossible  to 
restore  it,  and  where  the  woman  has  escaped  the  dangers  which 
the  acute  or  immediate  inversion  threatened  her.  We  omit  here 
the  antecedent  condition,  together  with  its  mode  of  treatment,  be- 
cause it  seems  to  belong  exclusively  to  a  system  of  midwifery. 

The  consequences  resulting  from  the  complete  inversion  of  the 
uterus  are  by  no  means  trifling,  should  the  woman  even  escape 
with  life.  She  will  necessarily  remain  for  a  long  time  weak,  not 
only  from  what  she  had  suffered  from  pain,  but  also  from  the 
loss  of  blood  which  attended  the  acute  stage  of  the  inversion. 
She  will  be  liable,  for  a  long  time,  to  a  sanguineous  discharge 
from  the  surface  of  the  uterus,  as  well  as  to  a  leucorrhoeal  one 
from  the  vagina.  In  consequence  of  which  she  may  become 
hectical,  and  die  from  exhaustion.  Great  care  is  required  on 
the  part  of  the  woman,  that  she  may  not  even  suffer  much,  from 
the  neglect  of  cleanliness.2 

It  will  be  seen,  by  referring  to  case  second,3  that  the  catame- 
nial  discharge  may  continue  with  perfect  regularity  for  some 
time.  It  will  then  cease,  most  probably,  from  the  influence  of 
the  external  air  upon  the  body  and  fundus  of  the  inverted  organ, 
by  altering  the  arrangement  of  its  secreting  surface. 

Astringent  injections  have  been  recommended,  and  they  have 
been  found  useful ;  more,  perhaps,  from  deterging  the  parts,  than 
from  any  other  influence.  They  should,  however,  always  be 
employed;  or  at  least  injections  of  some  kind  should  be  regularly 
persevered  in,  so  long  as  the  discharge  continues  to  be  too  abun- 
dant from  the  vagina. 

One  remarkable  circumstance  attends  the  inversion  of  the  ute- 
rus, which  is,  that  it  disqualifies  the  woman  for  conception,  at 

1  1  have  confined  myself,  in  this  place,  as  hinted  before,  to  the  chronic  condi- 
tion of  the  uterus  after  inversion ;  having,  in  my  System  of  Midwifery,  treated  at 
large  upon  the  acute  or  recent  inversion. 

*  We  were  lately  called  in  consultation  to  a  recent  case  of  "  Inversion."  The 
sufferings  of  the  patient  had  been  great,  and  the  hemorrhagy  exhausting.  Upon 
examination,  the  inversion  was  found  to  be  complete,  and  the  flooding  much  abated, 
though  the  discharge  was  still  considerable.  Rest,  nourishing  diet,  astringent  in- 
jections, the  extract  of  rhatany,  &c.,  were  prescribed  with  considerable  advantage, 
for  a  time;  but  about  every  two  or  three  weeks  there  would  be  a  return  of  he- 
morrhagy, which  would  continue  with  more  or  less  violence  for  several  days.  In 
this  way,  things  went  on  for  about  five  months,  by  which  time  the  patient  became 
so  reduced,  that  it  was  resolved,  in  consultation,  that  the  uterus  should  be  re- 
moved by  ligature,  as  the  only  chance  for  life — but  the  patient  died  before  the 
operation  could  be  performed. 

'  See  System  of  Midwifery,  p.  516. 


232  CHRONIC    INVERSION    OF    THE    UTERUS. 

least  for  a  uterine  one ;  if  she  be  able  to  conceive  at  all.  This, 
however,  appears  to  be  as  it  ought;  and  must  be  considered  as 
an  act  of  great  beneficence  on  the  part  of  the  Creator:  for,  did 
the  woman  conceive,  to  what  misery  would  she  be  doomed  at  its 
completion?  I  know  of  no  instance,  where  impregnation  has 
taken  place  after  an  inversion  of  the  uterus. 

Gardien  observes,  "Les  femmes  dont  la  matrice  n'a  pas  ete 
reduite  dans  les  premiers  temps  sont  probablement  inhabiles  a  la 
conception :  cependant,  une  observation  communique^  au  Profes- 
seur  Baudelocque  par  M.  Chevreul,  m6d6cin  d' Angers,  semble- 
rait  indiquer  que  la  conception  peut  encore,  s'operer  dans  1'une 
des  trompes  dont  les  extremit6s  uterines  s'ouvrent  dans  le  va- 
gin." — Vol.  iii.  p.  312.  This  observation  is  so  unsatisfactory, 
for  want  of  detail,  that  it  would  not  be  safe  to  consider  it,  even 
as  his  opinion,  that  it  was  an  instance  of  conception,  after  the 
inversion  of  the  uterus.  Besides,  he  has  not  indicated  from 
whence  he  derived  the  case,  that  more  light  might  be  received 
on  this  point.1 

A  woman  who  has  an  unreduced  uterus  does  not  necessarily 
die  suddenly,  or  even  eventually,  from  this  cause ;  since  a  few 
rare  cases  are  upon  record,  where,  after  such  an  event,  they 
have  enjoyed  for  some  time  a  tolerable  share  of  health:  this 
was  the  case  with  Mrs.  P.,  in  case  second,  before  referred  to; 
the  only  one  which  has  occurred  in  my  practice  of  an  unre- 
stored  uterus  after  an  inversion.2  I  have  seen  altogether  but 
eight  cases ;  three  of  which  were  fatal ;  two,  to  this  moment  re- 
main inverted ;  and  the  three  others  were  reduced  pretty  soon 
after  the  accident. 

The  fatal  termination  of  this  disease,  in  a  vast  majority  of 
cases,  seems,  however,  to  be  rather  the  result  of  improper  treat- 
ment, than  the  necessary  consequence  of  the  accident  itself.  From 
what  we  have  seen  of  this  complaint,  we  are  certain  that  much 
is  in  the  power  of  a  well  instructed  practitioner,  to  prevent  a 
fatal,  or  even  a  hazardous  termination :  for  the  disease,  we  re- 
peat, is  by  no  means  necessarily  fatal.3 

Experience  sufficiently  proves,  that  in  by  far  the  greater  num- 

1  It  is  much  to  be  regretted,  that  we  have  not  a  more  satisfactory  account  of 
this  case,  than  the  one  given  by  Gardien;  for  if  it  be  as  is  stated,  it  is  of  much 
physiological  consequence;  inasmuch  as  it  settles,  beyond  dispute,  that  the  direct 
conveyance  of  the  semen  through  the  os  uteri  is  not  the  mode  by  which  impreg- 
nation takes  place.  But  I  do  not  feel  myself  disposed  to  take  advantage  of  a 
statement  so  general  as  the  above  certainly  is,  to  enforce  what  I  have  so  fre- 
quently urged  against  the  doctrine  of  the  direct  conveyance  of  the  semen,  and  thus 
indirectly  strengthen  speculation  on  the  subject. 

'  Since  the  above  was  written,  I  have  met  with  another  instance  of  complete 
inversion,  and  which  has  now  become  chronic.  See  System  of  Midwifery,  art. 
Inversion  of  the  Uterus,  p.  464. 

*  Ruysch,  however,  says,  "  If  this  accident  be  not  immediately  remedied,  death 
presently  follows."  Obs.  X. 


CHRONIC    INVERSION    OF    THE    UTERUS.  233 

her  of  instances,  the  uterus  may  be  restored,  if  the  proper  mo- 
ment be  seized,  and  the  operation  be  properly  conducted;  for 
certain  it  is,  that  the  complete  inversion  rarely  takes  place  at 
once,  unless  it  be  from  some  improper  manceuvre  executed  upon 
the  placenta  ;  a  circumstance  which  cannot  well  happen  in  the 
hands  of  a  judicious  practitioner.  Though  we  must  admit  that 
the  inversion  may  happen  in  the  hands  of  the  best  instructed, 
and  most  careful  person,  as  he  cannot  foresee,  nor  always  pre- 
vent that  condition  of  the  uterus  which  gives  rise  to  it  ;  yet  the 
accident,  and  its  fatal  consequences,  will  be  comparatively  rare 
with  him.  And  when  it  does  occur  in  such  hands,  it  will  almost 
always  be  a  manageable  disease,  as  it  will  be  discovered,  before 
the  func^us  and  body  have  entirely  escaped  through  the  os  uteri, 
to  constitute  the  complete  inversion;  in  which  case  it  will  be 
rarely  otherwise  than  reducible. 

And  when  not  reducible,  though  the  inversion  be  not  com- 
plete, as  will  occasionally  happen,  immediate  death  may  perhaps 
be  prevented,  by  making  it  complete.  See  System  of  Midwifery, 
p.  464,  3d  edit. 

When  the  inversion  has  not  been,  or  cannot  be  reduced,  the 
woman  may  die  suddenly,  or  in  a  short  time,  from  the  profuse- 
ness  of  the  discharge  ;  or  she  may  linger  out  a  miserable  existence 
for  years.  Sufferings,  both  severe  and  long-continued,  await  the 
woman  who  has  an  unreduced  uterus  ;  her  life  is  that  of  misery 
and  wretchedness  :  and  these  augment  in  proportion  to  her  inca- 
pacity to  support  them.  Under  such  circumstances,  it  is  justi- 
fiable to  attempt  almost  any  thing  which  would  promise  relief. 
Hence,  it  has  been  proposed  to  remove  the  pendant  uterus  by 
excision  or  by  ligature. 

The  extirpation  of  the  uterus  is  not  a  novel  proposition  ;  it  has 
been  frequently  performed,  and  with,  perhaps,  a  fair  proportion 
of  success;  at  least  as  far  as  can  be  determined  by  the  histories 
of  cases  purporting  to  be  of  this  kind.  For  the  inverted  uterus, 
and  a  polypus  of  this  organ,  may  readily  be  confounded,  and  the 
mistake,  either  way,  may  give  rise  to  very  different  results. 

The  diagnostics  of  the  inverted  uterus,  and  a  polypus  of  this 
organ,  as  laid  down  by  writers,  are  both  vague  and  discrepant. 
This  has  created  no  small  embarrassment  and  uncertainty  in  the 
surgeon,  who  is  about  to  undertake  the  removal  of  the  tumour 
occupying  the  vagina;  since  he  cannot  satisfy  himself  of  the  real 
nature  of  the  disease  he  has  to  contend  with. 

Mr.  Newnham  appears  to  have  felt  all  this  uncertainty  in  its 
fullest  force,  when  he  was  about  to  apply  the  ligature  upon  the 
uterus,  and  he  makes  this  uncertainty  the  basis  of  his  essay  upon 
"inversio  uteri."  To  aid  his  judgment  in  this  interesting  and 
perplexing  case,  he  laboriously  consulted  almost  all  the  author!- 


* 


234  CHRONIC    INVERSION    OF   THE    UTERUS. 

ties  extant  ;  and,  after  carefully  collating  their  opinions,  he  re- 
duces them  to  the  following  summary. 

"  It  is  generally  remarked,  that  inversio  uteri  may  be  distin- 
guished from  polypus  of  that  organ  by  the  os  uteri  not  encircling 
the  former  tumour  in  cases  of  complete  inversion  :  and  by  the  im- 
possibility of  passing  the  finger  around  the  neck  of  the  tumour,  be- 
tween it  and  the  os  uteri,  where  the  inversion  has  been  only  partial; 
by  the  form  of  the  tumour,  the  polypus  being  broad  at  its  base,  and 
attached  by  a  narrow  peduncle,  while  the  inverted  uterus  is 
broader  above  than  below;1  by  the  insensibility  of  the  tumour  in 
the  one  case,  and  by  its  extreme  sensibility  in  the  other  ;  by  the 
comparative  fixity  of  the  one  tumour,  and  the  extensive  sphere  of 
motion  of  the  other;  by  the  rough  and  fungous  surface  of  inver- 
sion, contrasted  with  the  smooth  and  polished  surface  of  polypus  ; 
and  by  the  previous  history  of  the  patient's  disease."  "But  it 
is  clear,  that  these  diagnostics  are  liable  to  a  great  degree  of 
uncertainty,"  as  he  proves  by  most  ample  quotations. 

Mr.  Newnham  has  collected,  as  we  have  remarked,  with  great 
industry,  nearly  all  that  has  been  said  upon  the  diagnostics  of 
these  two  complaints  ;  and,  from  all  that  can  be  learned  from 
these  various  sources,  a  conclusion  must  be  drawn,  that  there  are 
none  which  are  absolutely  certain.  Mr.  N.  says,  "  On  reviewing 
the  foregoing  testimonies,  we  shall  be  induced  to  conclude,  that 
it  is  always  difficult  and  sometimes  impossible,  with  our  present 
knowledge,  to  distinguish  partial  and  chronic  inversion  of  the 
uterus  from  polypus  :  since,  in  both  diseases,  the  os  uteri  will  be 
found  encircling  the  summit  of  the  tumour,  and,  in  either  case, 
the  finger  may  be  readily  passed  around  it.  And  if,  in  order  to 
remove  this  uncertainty,  the  whole  hand  be  introduced  into  the 
vagina,  so  as  to  allow  the  fingers  to  pass  by  the  side  of  the  tu- 
mour, to  the  extremity  of  the  space  remaining  between  it  and  the 
os  uteri;  and  if  we  find  that  the  finger  soon  arrives  at  this  point, 
it  will  be  impossible  to  ascertain  whether  it  rests  against  a  por- 
tion of  the  uterus,  which  has  been  inverted  in  the  usual  way,  or 
by  the  long  -continued  dragging  of  polypus  upon  its  fundus. 
And  if,  under  these  embarrassing  circumstances,  we  call  to  our 
assistance  our  ideas  concerning  the  form  of  polypus,  its  enlarged 
base  and  narrow  peduncle,  we  must  also  recollect  the  abun- 
dant evidence  to  prove,  that  the  neck  of  such  a  tumour  is  often 

1  We  are  a  little  surprised  at  this  last  distinction;  for  certain  it  is,  we  have 
never  witnessed  an  instance  "  of  the  inverted  uterus  "  being  "  broader  above  than 
below;"  nor  can  we  imagine  how  this  can  exist.  We  are  every  way  sure,  that 
the  same  relative  proportions  exist  between  the  fundus  and  body,  and  that  of  the 
neck  in  both  the  natural  and  inverted  conditions  of  this  organ;  consequently,  the 
mark  mentioned  by  Mr.  N.  cannot  be  present,  but  by  some  unusual  arrangement  ; 
and,  of  course,  must  not  be  considered  as  a  diagnostic. 


CHRONIC   INVERSION   OF   THE   UTERUS.  235 

as  large,  and  sometimes  larger,  than  its  inferior  extremity ;  and 
we  shall  still  be  left  in  an  inexplicable  difficulty,"  p.  82. 

"But  shall  we  not  find  some  more  infallible  guide  in  those  other 
characteristics  which  have  been  given  as  certain  diagnostics  ? 

"  On  the  contrary,  we  shall  always  find  it  difficult  to  distinguish 
between  the  sensibility  of  the  tumour,  and  sensation  occurring  in 
neighbouring  viscera,  which  are  irritated  by  the  process  of  ex- 
amination,— while,  too,  it  must  be  remembered,  that  the  sensibi- 
lity of  the  inverted  uterus  is  greatly  diminished  in  its  chronic 
stage,  and  that  the  sensibility  of  polypus  may  be  increased  by 
the  presence  of  inflammatory  action ;  we  shall  ascertain  that  the 
degree  of  apparent  fixedness  of  the  tumour  will  depend  upon 
the  extent  of  its  attachment  to  the  uterus, — consequently,  the 
polypus,  with  a  considerable  stem,  will  be  fully  equal,  if  not 
greater,  than  in  the  inversion  of  the  uterus,  the  size  of  which  has 
been  diminished  by  time,  and  the  action  of  the  absorbents : — that 
in  either  case,  and  interchangeably,  according  to  the  different 
periods  and  circumstances  of  the  disease,  the  surface  of  the  tu- 
mour may  be  either  smooth  and  polished,  or  present  a  rough  and 
fungous  feel ;  and  that,  with  respect  to  the  previous  history  of  the 
case,  it  is  embarrassed  by  the  fact  that  polypi  have  been  produced 
in  the  uterus,  arid  have  only  first  passed  into  the  vagina,  im- 
mediately after  the  expulsion  of  the  foetus,  or  of  the  placenta. 
In  the  case  of  recent  inversion,  the  combination  of  some  of  these 
diagnostics  may  enable  us  to  decide  with  accuracy  on  the  nature 
of  the  case ;  but  they  are  insufficient  to  guide  our  judgment,  when 
we  are  first  called  to  give  our  opinion  on  the  disease  in  its  chronic 
stage,"  p.  83. 

The  case  which  gave  rise  to  the  above  conclusions  proved  to 
be  an  inverted  uterus ;  it  was  successfully  removed  by  the  liga- 
ture; and  the  woman  was  restored  by  the  operation  to  perfect 
health,  and  without  the  loss  of  those  feelings  which  it  is  thought 
have  their  origin  in  the  ovaria;  it  was  therefore  presumed,  that 
these  bodies  were  not  removed  with  the  uterus ;  neither  did  they 
appear  to  be  attached  to  the  removed  portion  of  the  uterus. 

The  mode  of  applying  the  ligature  is  not  described  by  Mr. 
N.;  but  we  presume  it  is  precisely  the  same  as  that  recommended 
by  Mr.  Clarke  for  the  removal  of  a  polypus.  See  Chapter  on 
Polypus. 


236      DISORDERS  AND  DISEASES   OF  THE   UTERUS. 


».«  n , 


CHAPTER  XIV. 

OF   THE   DISEASES   OF   THE    UTERUS,    OVARIA,    AND   TUBES. 

THE  whole  of  the  internal  organs  of  generation  are  liable  to 
diseases,  the  most  of  which  may  be  considered  as  incurable.  To 
describe  minutely  the  whole  that  are  known  would,  of  itself,  re- 
quire a  volume ;  and,  if  this  were  done,  we  might  be  disposed,  in 
many  instances,  to  inquire  for  the  cui  bono,  as  regards  the  suc- 
cess of  medical  treatment. 

Such  of  the  diseases  of  this  system  as  consist  in  sensible  alte- 
rations of  structure,  may  be  considered  as  arising  from  inflamma- 
tion of  one  or  more  of  the  tissues  composing  these  organs ;  or  from 
the  formation  of  tumours  which  have  originated  in  inflammation, 
either  acute  or  chronic,  the  existence  of  which  was  not  betrayed 
by  any  cognizable  symptom  in  its  incipient  state ;  or  into  such  as 
may  have  had  that  peculiar  beginning,  which,  by  the  application 
of  sufficiently  powerful  exciting  causes,  may  give  rise  to  malig- 
nant developments  that  may  prove  destructive  to  the  different 
surrounding  structures. 

SECT.  I. — Of  the  Disorders  and  Diseases  of  the  Uterus. 

The  affections  of  the  uterus  may  be  classed  under  the  follow- 
ing general  heads ;  and  were  we  disposed  to  enumerate  every 
departure  from  a  healthy  condition  we  might  make  very  many 
subdivisions,  without  adding  to  either  perspicuity  or  to  useful- 
ness : — 

1.  Imperfections  in  structure. 

2.  Variations  and  changes  of  structure. 

3.  Diseases  of  its  external  and  internal  surfaces. 

4.  Diseases  of  its  neck. 

1st.  Under  this  head  we  may  reckon, 

a.  When  this  organ  is  larger,  or.  smaller,  than  natural. 

b.  Where  the  neck  is  altogether  wanting. 
2d.  Under  this  head  may  be  comprised, 

a.  Extreme  smallness  of  this  organ. 

b.  Where  this  organ  is  double,  or  is  divided  into  two  com- 

partments. 

c.  Where  this  body  is  cartilaginous,  or  scirrhous. 
3d.   Under  this  head  may  be  classed, 

a.  Tumours  of  various  kinds. 

b.  Abscesses. 


DISEASES   OF  THE   OVARIES. 

c.  Ulcerations. 

d.  Cancer. 

e.  Tubercular,  cpongy,  or  polypous  excrescences. 
/.  Hydatids. 

g.  Cauliflower  excrescences. 
4th.  Under  this  head  may  be  included, 
a.  Cartilaginous  rings  of  the  os  uteri. 
6.  Its  complete  occlusion,  from 

1.  Excrescences  filling  it  up. 

2.  Stones  obstructing  it. 

3.  Membranes  forming  within  it,  and  from  membranes 

passing  over  it. 

4.  Scirrhous  tumours. 


SECT.  II. — Of  the,  Diseases  of  the  Ovaries. 

These  bodies  are  more  frequently  diseased  or  disordered  than 
the  uterus  itself;  but  neither  the  diseases,  nor  disorders  to  which 
they  are  liable,  are  of  such  dangerous  consequence.  They  are, 
however,  for  the  most  part,  more  occult  than  the  other  diseases 
of  the  genital  system,  if  we  except  those  of  the  tubes.  Hitherto 
no  remedy  has  been  discovered,  that  has  a  decided  operation  on 
these  bodies ;  consequently,  they  are  very  little  under  the  control 
of  remedies  whose  operations  are  felt  upon  the  general  system, 
or  of  those  which  may  exert  an  influence  on  certain  portions  of 
it.  It  is  probable,  that  during  an  active  state  of  disease,  as  in- 
flammation, the  usual  remedies  for  fever  or  inflammation,  may  be 
availing,  as  bleeding,  purging,  low  diet,  blistering,  &c.;  but  here, 
perhaps,  the  power  of  the  materia  medica  ceases :  for  no  one  in- 
stance, with  which  we  are  acquainted,  would  lead  us  to  the  con- 
clusion, that  any  remedy  has  removed  a  disordered  condition  of 
these  parts. 

They  seem  to  be  removed  so  far  from  the  general  sympathies 
of  the  system ;  so  insulated  in  position ;  so  independent  in  func- 
tion; that  the  common  agents  for-the  removal  or  control  of  dis- 
ease, seem  to  waste  themselves  in  unavailing  attempts  to  influence 
their  actions,  or  to  modify  their  affections.  Who  flatters  himself 
that  he  has  removed  a  dropsy ;  resolved  a  scirrhus ;  or  inter- 
rupted a  suppuration  in  these  bodies  ?  We  believe,  if  he  be  can- 
did, none  will  declare  he  has.  Little  more  then  is  ascertained, 
at  present,  than  that  these  parts  are  very  liable  to  disease,  and 
but  very  little  susceptible  of  cure.  But,  must  we  so  humble  the 
powers  of  the  healing  art,  as  to  declare  we  never  shall  be  master 
of  these  diseases?  Certainly  not.  Advances  are  constantly 
making  towards  the  improvement  of  this  branch  of  science, 
though  its  perfection  must  necessarily  be  remote ;  still,  from  time 


238  DISEASES   OF   THE   TUBES. 

to  time,  we  become  acquainted  with  substances,  which  have  a 
specific  action  upon  certain  tissues  of  the  human  body.  The  time 
may  arrive,  when  we  will  be  in  possession  of  a  substance,  the 
action  of  which  shall  be  confined  to  the  ovaries  alone,  or  to  simi- 
lar organizations,  if  any  such  there  be,  in  other  portions  of  the 
system.  But  until  then,  unfortunately,  the  victims  to  affections 
of  these  important  parts  must  remain  contented  with  the  solace 
which  palliatives  afford. 

The  affections  of  these  organs  may  be  classed  as  follows : 

1.  Scirrhous,  or  other  derangements  of  organic  structure. 

2.  The  entire  absence  of  the  organ  or  organs ;  if  a  negative 
may  be  assumed  for  a  positive  condition. 

3.  Contracted,  dry,  shrivelled. 

4.  Enormous  distention  of  them;  from  pus,  water,  fat,  &c. 

5.  Containing  extraneous  substances ;  as  hair,  bones,  teeth, 

&c. 

These  conditions  of  the  ovaries  are  far  from  being  very  rare ; 
Morgagni  alone,  from  his  own  observations,  furnishes  a  number 
of  instances  of  them ;  many  others,  who  have  been  attentive  to 
morbid  anatomy,  have  done  the  same.  For,  unfortunately,  they 
have  much  more  frequently  furnished  subjects  for  the  anatomist's 
knife,  than  triumphs  of  the  physician's  skill. 

Dr.  Robert  Lee  relates  the  following  cases,  and  shows  to  what 
extent  the  distention  may  go,  and  the  mischief  it  may  create. 
"In  a  case,"  says  he,  "under  my  own  observation,  (in  the  in- 
firmary of  Marylebone,)  an  ovarian  cyst  became  impacted  between 
the  bladder  and  rectum,  producing  all  the  symptoms  of  a  stricture 
of  the  rectum.  In  a  lady  now  under  our  care,  the  presence  of 
an  ovarium  or  uterine  tumour  in  the  pelvis,  which  presses  upon 
the  neck  of  the  bladder,  renders  it  impossible  for  the  bladder  to 
be  emptied  without  the  introduction  of  the  catheter."  Cyclop, 
of  Pract.  Med.  Art.  Ovaria,  p.  229. 

SECT.  III. — Of  the  Diseases  of  the  Tubes. 

The  alterations  in  structure,  which  these  bodies  undergo,  are 
different  from  those  to  which  the  ovaria  may  be  liable.  There 
is  rarely  any  other  change  in  these  bodies  than  that  which  inflam- 
mation produces,1  and  they  chiefly  consist, 

1.  In  the  obliteration  of  their  canals;  or  of  one  of  them. 

2.  In  adhesions  with  the  ovaria,  by  means  of  their  firnbriated 

extremities. 

3.  Sometimes,  in  a  great  distention  of  one  of  them,  from  the 

partial  development  of  an  ovum. 

'They  are,  however,  said  sometimes  to  be  involved, as  also  the  ovaria,  in  can- 
cer of  the  uterus. 


DISEASES    OF    THE    TUBES. 

The  diseases  of  the  tubes,  like  those  of  the  ovaries,  seem  to  be 
but  little  known  at  the  moment  at  which  we  might  anticipate 
success  from  treatment,  namely,  during  the  active  stage  of  the 
complaint.  That  these  bodies  are  much  more  frequently  inflamed 
than  is  generally  imagined,  we  should  infer  from  the  number  of 
instances  of  derangement  of  structure  which  dissection  brings  to 
light.  Yet  we  are  of  opinion,  that  few  practitioners  have  ever 
admitted  to  themselves  that  they  were  directing  their  remedial 
views  to  an  inflammation  of  one  or  both  of  these  bodies.  We 
have  every  thing  yet  to  learn,  as  regards  the  diagnostics  of  the 
diseased  tubes ;  for  to  this  moment  we  are  altogether  unacquainted 
with  the  portions  of  the  body  with  which  they  sympathize,  or 
what  parts  they  call  into  sympathy.  We  have,  in  a  number  of 
instances,  prescribed  for  a  deep-seated  pain  in  the  situation  we 
might  suppose  the  .tube  to  be ;  that  is,  a  little  to  the  right  or  to 
the  left  of  the  symphysis  pubis,  but  posteriorly.  If  the  part  be 
pressed  upon  pretty  firmly,  some  pain  will  be  felt ;  and  upon  turn- 
ing suddenly  in  bed,  will  be  sometimes  severely  acute.  There  is 
constantly  present,  an  aching,  obtuse  pain,  and  every  now  and 
then  a  lancinating  one.  There  is  a  frequent  desire  to  pass  water ; 
and  the  water  is  scantily  secreted :  after  passing  it,  a  pain  is  felt 
at  the  neck  of  the  bladder ;  the  urine  is  high-coloured,  and  of  a 
strong  alkaline  smell.  The  stomach  is  occasionally  sick,  and  easily 
provoked  to  vomit,  if  offended  by  medicine  or  food.  The  patient 
is  easier  on  her  back  than  side;  but  altogether  unable  to  sit  up 
without  great  agony.  Efforts  to  vomit  are  attended  by  severe 
pain ;  and  going  to  stool  is  also  attended  by  like  inconvenience. 
The  heat  of  the  skin  of  the  arms  and  hands,  is  below  the  natural 
standard;  but  other  portions  of  the  body  are  hotter  than  natural. 
The  tongue  furred;  and  a  constant  disagreeable  taste  in  the 
mouth.  The  pulse  rather  quick,  tense,  and  wiry.  No  disposition 
to  moisture,  though  occasionally,  without  knowing  why,  a  profuse 
perspiration  breaks  out,  but  without  tarrying  long  or  affording 
relief. 

The  pain  is  sure  to  be  aggravated  at  night ;  so  much  so,  some- 
times, as  to  prevent  the  patient  from  sleeping,  unless  under  the 
influence  of  strong  doses  of  opium;  and  these  are  not  always 
found  successful  in  destroying  the  severity  of  suffering. 

I  have  witnessed  this  pain  on  both  sides  of  the  pelvis  at  the 
same  time;  but  more  frequently  only  on  one.  In  all  the  instances 
I  have  seen  of  this  affection,  there  was  an  irregularity  of  the 
menses,  and  sometimes  a  total  suppression  of  them.  I  have  known 
the  pain  to  continue  from  two  weeks  to  three  months,  notwith- 
standing the  most  active  plans  were  pursued ;  such  as  bleeding, 
leeching,  cupping,  blistering,  purging,  rubefacients,  &c.  In  one 
instance  of  unusual  severity  and  pertinacity,  after  the  disease  had 
lost  its  acute  form,  it  was  removed  in  a  short  time  by  the  volatile 


240     PARTICULAR    DISEASES    OF    THE    UTERUS. 

tincture  of  guaiacum.  Before  this  remedy  was  employed,  the 
complaint  had  abated  much  of  its  severity;  though  the  patient 
suffered  considerably  at  the  time  it  was  commenced. 

I  am,  however,  by  no  means  certain,  that  the  disease  now  de- 
scribed, was  an  inflamed  tube  or  tubes ;  but  think  it  probable. 
That  it  was  a  disease  of  some  one  of  the  female  organs  of  genera- 
tion, I  am  pretty  firmly  convinced,  as  I  never  met  with  a  similar 
affection  in  the  male. 


CHAPTER  XV. 

OF  THE  PARTICULAR   DISEASES   OF  THE   UTERUS. 

Under  this  head  I  shall  consider  only  such  affections  as  attack 
the  substance  of  this  organ ;  and  shall  confine  myself  at  present 
to  carcinoma,  and  a  few  other  diseases  of  this  part.  The  many 
complaints  to  which  this  organ  is  liable,  and  with  which  every 
practitioner  should  be  familiar,  renders  it  necessary  to  give  a  full 
consideration  te  some  of  them,  while  others,  from  their  incurable 
nature,  will  require  little  more  than  their  history ;  as  the  method 
of  cure  is  unknown  to  us  at  present. 

Thus,  it  would  be  proper  to  dwell  upon  all  the  derangements 
of  menstruation,  menorrhagia,  leucorrhoea,  prolapsus,  retrover- 
sion,  inversion,  &c, ;  while  a  short  account  of  the  carcinoma,  cau- 
liflower excrescence,  corroding  ulcer,  &c.,  will  be  sufficient, 
as  we  are  unfortunately  acquainted  with  little  more  than  their 
ravages. 

The  diseases  about  to  be  considered  are  not  very  common  in 
this  country;  at  least,  they  would  appear  to  be  less  frequent 
here  than  in  Europe :  nor  is  this,  perhaps,  of  very  difficult  expla- 
nation. It  seems  to  follow,  as  a  natural  consequence,  that  that 
part  of  the  body  which  receives  the  most  injury  from  mechanical 
or  other  violence,  will  be  the  most  liable  to  disease ;  but  whether 
these  violences  be  capable  of  themselves  of  producing  an  original 
complaint,  like  carcinoma,  &c.,  or  only  act  as  exciting  causes 
upon  certain  predispositions,  remains  to  be  determined. 

We  are  of  opinion,  that  no  part  however  injured  will  suffer 
cancer,  unless  that  part  is  predisposed  to  it;  as  it  requires,  it 
seems  to  me,  a  certain  condition  of  the  part  before  it  takes  on  the 
cancerous  action,  and  that  predisposition  may  lie  dormant  until 
such  lesion  or  injury  is  done  to  it,  as  shall  excite  inflammation 
in  it ;  and  if  the  disposition  to  cancer  be  inflammation  or  ulcera- 


PARTICULAR,    DISEASES    OF   THE    UTERUS.         241 

tion,  it  will  run  on  to  one  or  other,  if  not  checked  by  suitable 
means,  and  it  will  terminate  in  cancer;  but  not  otherwise.  The 
inflammation  is  sui  generis,  and  must  have  its  appropriate  agent. 
Common  inflammation  may  be  successfully  combated  by  com- 
mon means  ;  but  not  so  the  inflammation  of  cancer.  Hence,  we 
see  inflammation  of  a  gland  or  glandular  part  treated  safely  and 
happily,  unless  there  be  a  disposition  to  cancer,  but  if  that  exist, 
the  consequences  are  always  to  be  dreaded.  Hence,  many  can- 
cers are  attributed  to  a  very  slight  degree  of  violence  in  the 
mamma,  especially  in  a  breast  so  disposed ;  but  double  the  force 
or  injury  to  the  breast  disposed  to  cancer,  will  prove,  perhaps, 
fatal ;  thus  we  find  scirrhus  generally  forerunning  cancer,  which 
latter  tendency  may  lay  dormant  for  many  years,  and  perhaps 
always,  if  not  called  by  accident  into  action.  Therefore,  the 
distinction  of  some  of  the  French  writers  has  no  foundation, 
namely,  "ulcer  and  ulcerated  cancers;"  the  former  intended  to 
signify  those  cases  where  the  ulceration  is  the  primary  affection, 
and  the  morbid  disposition  but  secondary;  whilst  in  the  latter 
case,  the  scirrhus  precedes  the  ulceration.  I  believe,  in  all  cases 
of  genuine  cancer,  a  state  of  scirrhus  precedes  the  ulceration, 
and  never  attacks  any  but  glandular  parts. 

Dr.  Churchill  says,  "  It  is  indisputable  that  in  other  parts  of  the 
body,  the  ulceration  may  occasionally  precede  the  cancerous 
disposition." — Churchill  on  the  Principal  Diseases  of  Females,  p. 
172. — Although  this  is  said  with  great  apparent  sincerity,  yet  it 
forces  no  conviction  on  my  mind.  In  this  it  is  similar  to 
scrofulus.  It  has  been  attributed  to  chronic  inflammation  by 
Broussais;  by  Copland  and  Andral,  an  altered  nutrition,  &c., 
all  of  which  goes  to  prove  that  we  know  nothing  about  it. — 
Churchill,  ib. — All  parts  of  the  uterus  are  liable  to  it,  but  some 
parts  appear  to  be  more  so  than  others,  as  the  neck  of  the  ute- 
rus, and  all  the  difference  in  phenomena  is  only  owing  to  the 
seat,  or  degree  of  development  of  the  morbid  structure. 

It  is  said,  on  the  authority  of  Dr.  Copland,  that  "the  fluid 
from  cancer  slightly  effervesces  with  sulphuric  acid,  and  turns 
the  syrup  of  violets  green." — Pract.  of  Med.  p.  285. 

Nor  will  the  development  of  its  intimate  structure  or  any  che- 
mical analysis  serve  to  explain  its  origin.  After  all  the  glands 
are  destroyed,  the  other  vessels  in  the  neighbourhood  seem  to 
take  on  a  healthy  action  or  inflammation  as  the  surrounding 
parts  will  be  agglutinated,  which  would  not  be  the  case,  did  the 
cancerous  disposition  obtain  in  all  of  them. 

We  believe  these  injuries,  however,  may  be  capable  of  doing 
both  the  one  and  the  other ;  but  the  character  of  the  diseases 
produced  under  these  different  circumstances,  will  be  very  diffe- 
rent.    Thus,  tumours,  or  other  indurations  of  the  uterus,  pass 
16 


^ 

242  CARCINOMA    UTERI. 

too  commonly  under  one  common  name,  as  scirrhi;  but  without 
scirrhus  being  the  disease.  While,  on  the  other  hand,  when  a 
predisposition  to  cancer  exists,  the  true  scirrhus,  or  carcinoma, 
may  be  formed  by  local  injuries ;  or,  if  formed,  they  may  make 
cancer  declare  itself. 

Now,  as  it  is  a  fact,  sufficiently  well  established,  that  tedious, 
laborious,  or  impracticable  labours  are  very  much  more  common 
in  Europe  than  in  this  country,  it  will  necessarily  follow,  that 
the  uterus  of  the  European  woman  is,  in  the  same  proportion, 
exposed  to  injuries  from  this  cause ;  consequently,  if  the  predis- 
position be  admitted  to  be  equal  to  the  women  of  both  countries, 
the  exciting  cause  will  be  more  rarely  applied  in  the  one  instance 
than  the  other ;  and  hence,  fewer  instances  of  cancer  uteri  in  the 
one  case  than  in  the  other. 

SECT.  I. — Of  the  Carcinoma  Uteri. 

Our  opportunities  of  seeing  this  disease,  as  well  as  that  of  the 
corroding  ulcer  of  the  uterus,  have  not  been  sufficiently  ample, 
to  make  us  rely  altogether  upon  our  own  observations,  for  their 
history,  appearances,  or  mode  of  treatment.  We  shall,  there- 
fore, mainly  depend  upon  the  descriptions  given  by  Mr.  Clarke, 
in  his  excellent  work  upon  the  diseases  of  females,  as  they  en- 
tirely agree  with  our  own  experience. 

Mr.  Clarke  observes,  that  cases  of  carcinoma  uteri1  are  fre- 
quently met  with  in  practice,  but  that  very  young  women  are 
seldom  attacked;  women  of  middle  age  are  much  more  liable  to 
it.  It  rarely  commences  with  violence ;  but  like  carcinoma  in 
other  parts  of  the  body,  becomes,  as  it  proceeds,  more  and  more 
distressing. 

It  attacks  at  first  only  the  neck  of  the  uterus ;  and  Mr.  Clarke 
lays  great  stress  upon  this  observation.  For  tumours  of  this  or- 
gan elsewhere  situated  are  of  a  different  character ;  having  dif- 
ferent symptoms  and  terminations.2  In  the  dead  body,  they  have 

*  "  By  carcinoma  uteri  is  meant  that  disease  where  there  is  a  tumour  near  to, 
or  a  thickening  of  the  cervix  of  the  uterus,  which  tumour  or  thickening  is  dis- 
posed to  ulcerate."— Diseases  of  Females,  p.  207.  Am.  Ed. 

1  Dr.  Mackintosh  gives  an  account  of  a  tumour  of  the  uterus,  and  which  he 
calls  a  "  vascular  sarcoma"  of  this  organ,  which,  upon  weighing  after  death,  was 
found  to  amount  to  more  than  fifty  pounds  avoirdupois.  •  He  observes,  "This  is, 
perhaps,  the  most  extreme  instance  upon  record,  particularly  in  which  life  was 
preserved  so  long  under  such  circumstances,  as  the  tumour  not  only  filled  the  ab- 
domen, but  pushed  the  diaphragm  so  high,  that  it  encroached  upon  the  thorax, 
and  lay  over  the  heart  and  lungs,  so  as  to  conceal  the  respiratory  sound  over  the 
whole  anterior  part  of  the  chest."  "  On  cutting  into  a  uterus  affected  with  vas- 
cular sarcoma,  there  is  observed  not  only  a  resemblance  to  the  natural  structure, 
but  a»- absence  of  those  lines  which  characterize  scirrhus." — Mackintosh's  Prac- 
tice of  Physic,  Vol.  II.,  p.  314. 


CARCINOMA    UTERI.  243 

• 

some  resemblance  to  carcinoma,  but  they  are  never  found  ulce- 
rated. 

Carcinoma  particularly  affects  glandular  parts;  hence,  its  at- 
tack of  the  neck  of  the  uterus. 

Tumours  of  a  large  size  have  frequently  been  called  scirrhi, 
because  they  are  hard  in  their  texture :  but  the  true  carcinoma 
seldom  become  very  large.1 

A  sense  of  weight  is  felt  in  the  vagina ;  a  discharge  of  mucus 
sometimes  tinged  with  blood,  or  sometimes  pure  blood,  after  ex- 
ercise, comes  away,  and  this  in  sufficient  quantity  at  times  to 
weaken  even  to  fainting.  Menstruation,  if  it  have  not  ceased, 
becomes  irregular,  and  more  abundant  than  ordinary. 

Strangury  almost  always  attends ;  the  inner  membrane  of  the 
bladder  secretes  a  transparent  mucus,  which  falls  to  the  bottom 
of  the  urinal.  Pain,  like  the  passage  of  a  calculus  from  the  kid- 
ney to  the  bladder  is  felt,  and  urticaria,  heartburn,  &c.,  attend. 

Care  must  be  taken  that  these  various  affections  of  the  sto- 
mach be  not  mistaken  for  the  disease ;  as  they  are  only  symp- 
tomatic of  the  condition  of  the  uterus — they  augment  as  the  dis- 
ease advances,  and  much  mischief  would  ensue,  if  they  were 
treated  as  original  diseases. 

An  examination  per  vaginam  should  always  be  requested.  If 
the  disease  be  carcinoma,  the  cervix  of  the  uterus  will  be  found 
thickened,  and  resisting  like  gristle ;  or  a  distinct  tumour  will 
be  perceived  on  some  part  of  the  neck  of  the  uterus ;  the  other 
portions  remaining  healthy.  In  either  case,  pressure  produces 
a  lancinating  pain.* 

1  Dr.  Homer  and  myself  attended  a  lady  with  carcinoma,  complicated  with  a 
polypus  nearly  the  size  of  a  hen's  egg,  which  masked  in  great  measure  the  condi- 
tion of  the  neck  of  the  uterus  until  it  was  removed  by  ligature.  After  the  re- 
moval of  the  polypus,  the  neck  of  the  uterus  was  found  to  be  ulcerated  to  a  con- 
siderable extent;  indeed,  all  round,  with  the  exception  of  the  spot  to  which  the 
pedicle  of  the  polypus  was  attached.  The  patient  for  some  time  remained  very 
weak  from  the  excess  of  discharges:  they,  however,  diminished,  and  the  ulcera- 
tion  of  the  neck  of  the  uterus  was  reduced  to  a  surface  not  exceeding  the  size  of 
a  ten  cent  piece;  the  discharge  from  the  vagina  was  scarcely  any,  and  of  a  healthy 
appearance;  strength  was  rapidly  returning; — in  a  word,  every  thing  gave  pro- 
mise of  a  recovery.  But  unfortunately,  the  patient,  a  little  careless  when  about 
to  sit  down,  fell  with  considerable  force  upon  her  seat,  which  gave  her  great  pain, 
— hemorrhage  to  some  extent  followed,  by  which  she  was  very  much  reduced, 
and  eventually  died  from  exhaustion. 

*  It  is  now  well  ascertained,  that  there  are  many  affections  of  the  neck  of  the 
uterus  that  are  not  eardiiomatous.  We  have  seen  a  number  of  this  kind ;  a  kind 
that  at  first  alarmed  us  much;  but  which,  by  a  proper  mode  of  treatment,  yielded 
eventually,  if  not  suddenly,  to  our  remedies.  The  remedies  which  are  proper  to 
the  treatment  of  incipient  carcinoma,  are  precisely  such  as  will  prove  beneficial 
in  the  various  intumescences  of  the  neck  of  the  uterus — but  especially,  local  bleed- 
ing, severe  diet,  and  absolute  rest.  Leeching,  immediately  from  the  uterus,  is 
incomparably  better  than  more  remote  leeching;  and  notwithstanding  the  great 
aversion  our  American  ladies  have  to  this  mode  of  depletion,  we  are  happy  to  say, 
we  have,  in  a  number  of  instances,  been  able  to  overcome  this  reluctance,  from 


244  TREATMENT   OF   CARCINOMA    UTERI. 

The  os  uteri  will  be  found  changed.  It  becomes  larger,  though 
it  retains  its  shape — it  will  sometimes  admit  the  extremity  of  the 
finger.  Patients  rarely  die  during  the  carcinomatous  state  of 
.the  disease;  when  they  do,  it  is  in  consequence  of  frequent  he- 
morrhagies. — Clarke  on  Female  Diseases. 


SECT.  II. — Of  the  Treatment  of  Carcinoma  Uteri. 

,   '„    -U.-y-r        /V.f '••"*•'  M-'*W    ;'"V'".-'; 

It  seems  to  be  a  doubtful  point,  by  those  best  acquainted  with 
this  complaint,  whether  a  cure,  or  mere  suspension  of  the  disease 
has  ever  been  effected.  Mr.  Clarke,  with  all  that  caution  which 
characterizes  the  honest  practitioner,  thinks  he  has  cured  this 
affection  in  its  incipient  state,  though  he  dare  not  absolutely  avow 
it.  We  feel  ourselves  precisely  in  the  same  predicament — we 
have  had  two  cases  very  similar  to  those  described  by  Mr. 
Clarke;1  in  both  of  which  there  was  a  restoration  of  the  neck  of 
the  uterus  to  its  natural  size,  with  an  entire  cessation  of  all  the 
previous  distressing  symptoms ;  these  may  not  have  been  genuine 
cases  of  carcinoma,  though  we  believe  they  were. 

which  they  have  derived  the  most  prompt  and  satisfactory  advantage.  One  lady, 
who  had  numerous  tumours  about  the  neck  and  pelvic  portion  of  the  body,  wag 
entirely  relieved  of  them  by  persevering  in  the  use  of  the  ext.  conii;  she  began 
with  a  grain  three  times  a  day,  and  gradually  increased  it  until  it  amounted  to 
one  ounce,  and  one  ounce  and  a  drachm  per  day. 

1  Since  this  time,  two  other  similar  cases  have  presented  themselves,  both  of 
which  have  been  entirely  relieved.  One  of  these  cases  presents  so  much  interest 

that  I  shall  briefly  relate  it.     Mrs. has  suffered,  for  seven  or  eight  years, 

constant  pain  in  the  pelvis,  which  at  times  becomes  highly  aggravated,  especially 
during  the  menstrual  period.  This  discharge  is  sparing,  very  dark-coloured,  and 
irregular.  There  is  some  leucorrhosa,  which  is  rather  offensive,  if  the  utmost  care 
be  not  paid  to  cleanliness.  The  pain  during  the  menstrual  flow  is  extreme,  and 
almost  always  attended  by  strong  hysterical  paroxysms;  strength  impaired,  appe- 
tite feeble  and  whimsical;  feet  swollen,  but  not  excessively;  very  pale,  and  eye- 
lids tumid  in  the  morning;  pulse  corded  and  irritated.  The  case  has  been  treated 
as  one  of  difficult  menstruation;  all  remedies,  so  far,  have  rather  tended  to  increase 
her  sufferings.  An  examination,  per  vaginam,  discovers  the  uterus  enlarged,  its 
neck  much  swollen,  a  number  of  small  hard  tumours  placed  up  it,  and  as  much  of 
the  body  of  this  organ  as  can  be  felt  in  the  vagina.  The  uterus  precipitated  so 
much  as  to  rest  upon  the  face  of  the  perineum — the  whole  space  left  in  the  vagina 
will  not  exceed  that  of  a  small  wine  glass.  The  vaginal  parietes  dense,  and  un- 
yielding— the  whole  of  the  parts  that  can  be  touched  with  the  finger  exceedingly 
painful,  especially  the  neck  of  the  uterus.  Coition  impracticable,  or  nearly  so. 
The  subject  is  young,  that  is,  twenty-six  years  of  age;  has  been  married  eight  or 
nine  years,  but  never  has  conceived. 

Rest  upon  the  bed  almost  absolute — regimen  strictly  antiphlogistic — leeches  to 
thigh  every  three  weeks — purge  every  other  day  with  jalap  and  cream  of  tartar— 
live  absque  marito — warm  water  injections  per  vaginam  three  times  a  day. 

This  plan,  with  very  trifling  variations,  was  continued  for  thirteen  months; 
the  parts  by  this  time  were  restored  to  their  natural  condition,  as  regards  feeling 
and  form.  Suffers  no  inconvenience  from  matrimonial  intercourse  :  catamenia  re- 
gular, and  sufficiently  abundant.  This  improved  condition  has  continued  now  for 
fourteen  months  without  interruption — in  a  word,  the  patient  considers  herself 
perfectly  restored  to  health. 


4 

TREATMENT   OF   CARCINOMA   UTERI.  245 

Nor  do  we  see  any  thing  very  irreconcilable  in  the  case ;  for 
if  proper  means  be  duly  employed,  they  will  almost  surely  be 
attended  with  advantage,  if  without  absolute  success ;  and  if  the 
ulcerative  process  be  prevented,  or  even  retarded,  which  we  are 
disposed  to  believe  will  often  happen,  very  much  is  gained.  In- 
deed, it  is  very  well  known  that  this  disease  is  held  long  in  sub- 
jection by  the  continuance  of  the  menstrual  discharge,  and  a 
temperate  mode  of  living.  And  from  this  very  circumstance  a 
valuable  practical  hint  may  be  taken,  in  the  management  of  this 
disease. 

The  first  object,  in  the  treatment  of  carcinoma  uteri,  is  to  pre- 
vent ulceration  from  taking  place ;  this  is  to  be  done  by  the  re- 
duction of  the  local  inflammation,  (which  is  essential  to  the  dis- 
ease,) by  such  means  as  are  best  calculated  to  diminish  the  quan- 
tity of  circulating  blood,  and  to  abate  arterial  action. 
These  ends  will  be  found  best  answered  by 

1st.  Blood-letting,  both  general  and  locaL 

2d.  By  purging. 

3d.  By  an  abstemious  diet. 

4th.  By  cleanliness. 

5tL  By  rest. 


1.  Abstracting  Blood, 

We  believe  that  an  increased  pulse  always  attends  this  disease, 
when  it  declares  itself  by  pain  in  the  lower  region  of  the  uterus, 
and  an  increase  of  the  vaginal  discharge.  If  the  arterial  system 
be  not  found  at  such  times  absolutely  preternaturally  increased, 
it  is  sure  to  be  most  easily  excited.  On  this  account,  the  ab- 
straction of  a  few  ounces  of  blood  becomes  highly  important 
from  time  to  time;  but  if  the  catamenia  have  ceased,  it  becomes 
absolutely  necessary.  This  may  be  taken  from  the  arm,  when 
considerable  arterial  excitement  is  present;  and,  so  far  as  we 
have  witnessed,  it  has  been  found  with  considerable  buff,  or  even 
cupped. 

If  there  be  less  excitement,  and  particularly  if  there  be  a  se- 
vere throbbing  pain  just  above  the  sacrum,  much  immediate  re- 
lief is  found  from  losing  six  or  eight  ounces  of  blood  by  either 
cupping  or  leeching.  We  have  found  it  necessary  to  have  this 
operation  repeated,  sometimes  every  three  or  four  weeks. 

We  are  generally  directed  to  abstract  blood  from  such  patients 
as  may  be  plethoric ;  this  is  certainly  a  proper  direction,  so  far 
as  it  goes — but  no  farther;  for  it  seems  to  forbid  this  operation, 
when  this  state  of  fulness  is  not  manifestly  present :  now,  were 
this  operation  to  be  withheld  for  the  want  of  this  evidence,  we 
should  very  often  deprive  the  patient  of  the  best  means  of  relief, 


TREATMENT   OF   CARCINOMA   UTERI. 

though  that  relief  may  be  but  temporary.  We  have  constantly 
found,  when  pain  was  severe,  the  pulse  frequent  and  tense,  or 
wiry;  (for  so  it  will  almost  always  be  found  in  these  cases,)  the 
skin  hot,  and  sleep  uncertain,  that  the  abstraction  of  a  few  ounces 
of  blood  would  afford  not  only  considerable  relief,  but  would 
place  the  system  in  a  better  condition  for  narcotics,  so  indispen- 
sable in  such  cases. 

Besides,  it  seems  to  lessen  the  hemorrhagic  tendency  of  the 
uterus ;  and  thus  abates  the  discharge  of  blood,  which  might 
otherwise  be  too  abundant.  We  generally  prefer  local  bleeding, 
when  it  can  conveniently  be  had  recourse  to ;  as  its  effects  are 
more  decided,  and  diminishes  the  strength  less.  But  we  have 
no  experience  ourselves  to  authorize  us  to  decide  whether  it 
will  be  best  abstracted  from  the  back  or  abdomen.1  Mr.  Clarke 
says,  "  The  relief  produced  by  topical  blood-letting  is  great,  and 
often  immediately  felt :  blood  is  generally  procured  more  easily, 
when  the  cupping-glasses  are  applied  to  the  back,  than  when 
they  are  placed  upon  the  abdomen.  Nevertheless,  when  blood 
can  be  procured  in  sufficient  quantity  from  the  lower  part  of  the 
abdomen,  it  will  be  proper  to  direct  that  it  should  be  so  taken, 
especially  when  cupping  on  the  back  has  failed  to  produce  the 
expected  advantage,"  p.  266,  Vol.  I.  Leeches,  applied  to  the 
vulva,  have  had,  we  think,  a  more  prompt  effect  than  when  ap- 
plied to  the  back;  and  we  are  informed  by  Guilbert  and  Du- 
parcque,  that  when  applied  early  to  the  neck  of  the  uterus  itself, 
that  leeching  is  still  more  useful:  this  assurance  not  only  applies 
to  the  early  stages  of  the  disease  under  consideration,  but  in  an 
especial  manner  to  the  chronic  phlegmasise  of  the  uterus,  when 
attended  with  an  engorged  condition  of  its  neck.  The  efficacy 
can  be  easily  believed ;  but,  to  get  our  fair  countrywomen  to 
submit  to  these  applications,  I  fear  will  be  a  work  of  no  small 
difficulty — yet  it  should  be  overcome,  as  it  may  save  them  from 
the  most  loathsome  and  painful'of  all  the  diseases  to  which  the 
sex  is  liable.  We  therefore  hope,  in  due  time,  to  see  the  preju- 
dices which  now  interdict  the  application  of  leeches  immediately 
to  the  neck  of  the  womb,  done  away,  as  the  health  and  happiness 
of  thousands  will  depend  upon  their  cessation.  We  well  remem- 
ber the  time,  when  it  was  nearly,  if  not  entirely,  as  repugnant 
to  the  female  to  receive  a  common  clyster,  as  it  would  be  now, 
perhaps,  to  submit  to  the  use  of  leeches  in  the  way  just  inti- 
mated. At  all  events,  we  feel  it  a  duty  to  put  the  public  in  pos- 
session of  every  valuable  or  useful  remedy  that  experience  has 
justified;  leaving,  of  course,  its  application  to  the  choice  of  the 

1  For  the  last  few  years,  we  have  been  in  the  habit  of  abstracting  the  blood 
from  the  inner  surface  of  the  thigh,  as  it  seems  to  afford  more  immediate  relief ; 
for  blood  can  be  abstracted  with  more  rapidity  and  certainty  from  this  part,  than 
from  either  the  back  or  abdomen.  Besides,  its  revulsive  power  may  have  a  salu- 
tary influence. 


TREATMENT   OF   CARCINOMA  UTERI.  247 

individuals  concerned.  As  regards  ourselves,  we  have  but  too 
frequently  had  cause  to  lament  this  overweening  delicacy,  as  we 
are  certain,  in  many  instances,  that  have  fallen  under  our  notice, 
cures  might  have  been  performed,  where  only  relief,  and  that 
sometimes  but  temporary,  was  procured.  So  far,  it  has  been  our 
misfortune  to  have,  in  no  instance,  a  single  compliance  with  this 
prescription ;  but  we  do  not  despair  that  we  may  yet  overcome 
this  injurious  reluctance. 
.--..•  '  '':  .  ••>;.  :./  •.'.,'',  •  • 

2.   Purging. 

This  should  never  be  omitted ;  for  there  is  no  one  remedy  that 
we  can  employ  in  this  deplorable  disease,  that  is  of  such  decided 
efficacy  as  purging.  It  not  only  comports  with  the  general  ob- 
jects to  be  fulfilled,  but  it  removes  a  prodigious  source  of  irrita- 
tion. 'In  conducting  this  process,  however,  regard  must  be  had, 
1st,  to  the  quality  of  the  purgative ;  2d,  to  the  extent  to  which 
this  must  be  carried;  and,  3d,  to  the  effects  it  produces. 

1.  It  is  not  a  matter  of  indifference  which  of  the  purgatives 
we  select  for  the  purpose  of  affecting  the  bowels,  in  the  disease 
under  consideration.  Such  should  always  have  the  preference 
as  will  sit  best  upon  the  stomach  ;  that  will  operate  without  pain, 
and  afford  copious  discharges  of  fluids  from  the  intestines  them- 
selves. Such  are  the  neutral  salts;  they  therefore  merit  the 
preference.  The  sulphate  of  magnesia  alone,  or  combined  with 
an  equal  weight  of  the  magnes.  alb.  ust. ;  phosphate  of  soda;  the 
Seidlitz  powders ;  crem.  tart,  and  the  flor.  sulp.  in  equal  quanti- 
ties ;  and  the  sulphur  and  magnesia.  Next  to  the  neutral  salts, 
we  may  place  rhubarb,  or  rhubarb  and  aloes;  the  castor  oil,  the 
magnesia  alone,  &c. 

Mr.  Clarke  recommends,  "when  saline  purgatives  do  not  agree 
with  the  stomach,  but  excite  vomiting,  an  additional  quantity  of 
acid  may  be  given  with  them :  thus,  eight  or  ten  drops  of  diluted 
sulphuric  acid  may  be  added  advantageously,"  p.  227. 

We  have  known  a  saturated  solution  of  the  sulphate  of  soda, 
or  of  magnesia  in  small  doses,  repeated  every  morning,  or  every 
other  morning,  continue  to  agree  with  the  stomach  admirably, 
for  months  together,  and  move  the  bowels  freely  two  or  three 
times  a  day,  without  either  nausea  or  pain.  This  solution  must 
be  taken  in  the  quantity  of  a  large  table-spoonful,  early  in  the 
morning,  before  eating;  and,  contrary  to  expectation,  it  sits  well 
upon  the  stomach. 

This  solution  is  not,  however,  always  sufficiently  powerful  to 
keep  the  bowels  soluble ;  when  this  happens,  a  little  calcined 
magnesia  must  be  added.  Where  those  medicines  would  be  dis- 
gusting, the  phosphate  of  soda,  the  Seidlitz  powders,  the  cream  of 
tartar  and  brimstone,  or  brimstone  and  magnesia  may  be  substi- 


248  TREATMENT   OF  CARCINOMA   UTERI. 

tuted.     The  castor  oil  occasionally  may  be  resorted  to,  but  it  does 
not,  in  general,  answer  well,  when  continued  for  a  long  time. 

I  have  mentioned  rhubarb,  as  the  next  best  general  cathartic; 
this  is  a  valuable  medicine  in  almost  all  cases,  where  a  perse- 
verance in  purgative  remedies  is  absolutely  necessary,  as  it  very 
seldom  requires  an  increase  of  dose  if  it  be  regularly  adminis- 
tered. But  it  happens  with  it,  as  with  every  other  medicine, 
that  it  will  sometimes,  though  rarely,  lose  its  effect;  when  this 
happens,  it  should  be  combined  with  aloes.  The  following  is  the 
formula  I  generally  employ: — 

R.  Gum  Aloes,  sue.  gss. 

Pulv.  Rhsei.  3J. 

Ol.  Caryoph.  gut.  iv. 

Sapo  Venet.  gr.  viij. 

Syr.  Rhsei.  q.  s.  M.  f.  pil.  xxx. 

One  of  these  is  to  be  taken  every  night,  or  every  other  night,  as  they  may 
affect  the  bowels. 

This  form  rarely  requires  an  increase  of  dose,  unless  the  bowels 
are  rendered  costive  by  opium,  which  is  very  likely  to  happen, 
as  this  drug  must  be  used  in  this  complaint:  if  this  happen,  two 
or  three  of  the  pills  may  be  required. 

It  is  familiar  to  us,  that  aloes  is  generally  prescribed  in  all 
cases  where  the  uterus  yields  blood  too  frequently,  or  in  too 
large  a  quantity;  but  we  believe  this  to  be  an  ill-founded  preju- 
dice. We  have  used  the  pills  now  prescribed  in  several  instances 
of  this  complaint  with  entire  success,  as  regards  the  object  for 
which  they  were  ordered ;  namely,  to  gently  purge  the  bowels ; 
and,  certainly,  without  increasing  the  inconveniences  under  which 
the  patient  was  labouring. 

It  happens  not  unfrequently  that  the  bowels  become  obstinately 
costive:  nor  can  they  be  made  amenable  to  common  remedies, 
even  in  large  doses:  this  condition  is  most  unfortunate  for  the 
patient;  for  it  not  only  deprives  her  of  the  advantages  which  con- 
stantly result  from  purging,  but  aggravates  by  a  mechanical 
agency  all  the  evils  of  her  situation.  In  such  cases,  the  bowels 
should  be  emptied  by  mild  injections,  when  they  can  be  thrown 
up  the  rectum ;  this  sometimes,  however,  is  a  matter  of  great  dif- 
ficulty, but  they  should  be  made  to  act  rather  by  their  bulk  than 
by  their  quality.  The  common  stiff  pipe,  attached  to  a  syringe, 
is  but  ill-calculated  to  succeed  in  cases  where  the  rectum  is  par- 
tially obliterated  by  the  enlarged  uterus  pressing  against  it :  a 
flexible  tube  should  always  be  used,  when  this  difficulty  occurs. 

2.  The  extent  to  which  purging  must  be  carried,  is  next  to  be 
considered.  It  will  readily  occur,  that  this  process  should  have 
a  limit;  or  much  mischief  must  ensue;  indeed,  its  very  objects 
would  be  frustrated.  The  use  of  purging  is,  to  solicit  large 
serous  discharges  from  the  intestines,  with  a  view  to  relieve  the 


TREATMENT    OF    CARCINOMA    UTERI.  249 

engorged  state  of  the  pelvic  viscera,  and  at  the  same  time  not 
to  weaken  the  system  too  much  by  its  excess ;  consequently,  if 
purging  be  carried  too  far,  we  shall  have  the  following  incon- 
veniences to  contend  with ;  1st,  the  body  will  be  unnecessarily 
debilitated  from  the  excess  of  discharge;  2d,  we  shall  have  mu- 
cous discharges,  instead  of  serous,  which  will  be  attended  by 
griping  pains ;  3d,  instead  of  lessening  the  congestive  tendency 
of  these  parts,  it  will  increase  it,  by  producing  a  sub-inflammation 
of  the  intestines ;  4th,  we  should  increase  the  activity  of  the 
inflammation  in  the  neck  of  the  uterus,  by  the  mechanical  pres- 
sure of  the  sigmoid  flexion  of  the  colon  and  rectum,  in  the  act 
of  passing  the  feces.  Therefore,  more  than  two  or  three  easy 
stools  per  day  have  ever  proved  both  inconvenient  and  injurious, 
by  the  disturbances  they  create  during  their  passage. 

3.  Regard  must  be  paid  to  the  effects  purging  produces.  This 
must  be  determined,  1st,  by  whether  the  discharges  are  attended 
with  much  pain  during  the  operation,  or  immediately  after:  if 
they  are,  the  number  of  discharges  must  be  diminished;  unless 
the  pain  arise  from  the  costive  condition  of  the  bowels ;  2d,  by 
whether  these  discharges  produce  faintness,  or  other  decided 
signs  of  weakness:  if  they  do,  they  should  be  moderated;  or,  if 
judged  proper,  even  suspended  for  awhile. 


8.  Abstemious  Diet. 

There  is  no  disease,  unless  it  be  one  very  much  more  acute, 
that  so  decidedly  suifers  aggravation  from  errors  in  diet,  as  the 
one  under  consideration.  We  have  known  severe  and  long-con- 
tinued pain  to  follow  an  apparently  slight  error  in  diet.  For,  it 
would  seem  evident,  that,  if  any  expectation  be  entertained  of 
curing,  or  even  alleviating  this  complaint,  that  diet,  like  every 
thing  else  remedial,  should  be  made  conformable  to  the  great  in- 
dications ;  namely,  to  diminish  the  quantity  of  circulating  fluids ; 
and  to  abate,  both  locally  and  generally,  arterial  aetion. 

Therefore,  the  most  bland  articles  must  be  selected  for  this 
purpose ;  as  milk  and  vegetables.  If  milk  agree  with  the  patient, 
as  a  general  article  in  diet,  it  should  be  used  in  preference  to 
almost  any  other;  it  may  be  taken  a  little  reduced  by  water, 
three  times  a  day  with  bread,  rice,  Indian,  or  rye  mush,  or  un- 
bolted wheat  flour  mush ;  but  especially  the  last,  as  there  is  almost 
always  costiveness.  The  fruits  of  the  season,  tapioca,  oatmeal, 
sago,  Indian  meal  gruel,  &c.,  may  also  be  taken,  the  rennet  whey, 
where  the  whole  milk  disagrees ;  in  a  word,  almost  any  vegetable 
that  is  neither  stimulating  nor  of  difficult  assimilation. 

It  is  well  known  that  food  may  offend  by  its  quantity,  as  well 


TREATMENT    OP    CARCINOMA    UTERI. 

as  by  its  quality ;  and  though  we  have  admitted  a  great  variety 
of  vegetable  substances,  it  must  be  understood  that  those  must 
be  moderately  indulged  in ;  otherwise  they  may  offend  by  their 
quantity. 

The  influence  of  this  course  of  diet  is  much  more  efficient  than 
we  might  at  first  be  willing  to  admit ;  but  the  fact  is  unquestion- 
able, that  it  almost  immediately  relieves  pain,  after  it  has  been 
adopted. 

Mr.  Clarke  very  well  observes,  that  "the  quantity  of  food 
taken  should  be  very  moderate;  lest,  not  being  digested,  it  should 
disturb  the  functions  of  the  alimentary  canal,  and  become  the 
cause  of  fever ;  or  lest,  being  digested,  it  should  add  to  the  quan- 
tity of  blood,  and  improperly  increase  the  vigour  of  the  system," 
p.  229. 

The  patient,  it  must  be  remembered,  must  be  forbidden,  at  the 
same  time,  every  kind  of  stimulating  drink.  Wine,  spirits,  and 
fermented  liquor  of  every  sort,  must  be  prohibited  with  even 
more  rigor,  if  possible,  than  animal  substances,  as  food.  Spices, 
or  any  other  condiment,  must  be  considered  as  coming  under 
the  same  ban. 

"  All  local  stimuli  should  of  course  be  avoided.  Sexual  inter- 
course must,  therefore,  be  improper."  Clarke,  p.  229. 


4.  By  Cleanliness. 

Nothing  can  compensate  for  the  want  of  cleanliness ;  yet,  in 
this  case,  some  care  is  required,  to  conduct  it  with  advantage. 

In  the  history  just  given  of  carcinoma,  it  was  observed  that 
there  was  an  increase  of  vaginal  discharge.  This,  if  permitted 
to  accumulate,  or  suffered  to  undergo  the  changes  which  heat 
always  effects  upon  the  fluids  when  thrown  off  from  the  system, 
would  become  offensive  and  highly  acrid;  consequently,  would 
increase  the  irritable  condition  of  the  cervix  uteri,  from  its  prox- 
imity and  even  contact  with  it. 

It  therefore  behooves  the  female  to  keep  these  parts  extremely 
clean,  by  frequent  ablutions  with  lukewarm  water,  or  flaxseed 
tea,  as  well  as  deterging  the  vagina  with  the  same  material,  by 
means  of  the  female  syringe.  Many  have  thought  to  improve 
the  efficacy  of  these  mild  applications,  by  the  addition  of  certain 
medicaments ;  but  we  believe,  that  advantage  has  rarely,  if  ever, 
been  gained  by  this  practice ;  unless  a  substance  has  been  ex- 
pressly added  to  destroy  the  fetor  of  the  discharge,  by  its  che- 
mical agency. 

If  the  disease  has  proceeded  to  ulceration,  the  smell  sometimes 
becomes  almost  insupportable;  for  now  a  quantity  of  blood  is 
almost  constantly  issuing  from  the  ulcerated  surface,  which, 


TREATMENT    OF    CARCINOMA    UTERI.  251 

becoming  putrid,  gives  out  so  pestiferous  a  gas,  that  few  can 
support  its  presence  without  great  aversion,  or  even  nausea. 

The  patient  herself  becomes  much  annoyed  by  this  stench ; 
often  so  much  so,  as  to  deprive  her  of  both  appetite  and  sleep; 
she  quickly  becomes  debilitated,  even  sometimes  to  exhaustion, 
from  this  cause.  All  her  evils  are  increased  by  the  pervading 
influence  of  this  odour;  her  digestive  powers  are  so  weakened, 
as  to  reject  the  little  sustenance  a  wretched  appetite  allows  her 
to  take ;  and  the  effort  to  puke  may  renew  a  hemorrhage,  which 
had  been  but  a  short  time  before  arrested  with  difficulty.  We 
once  witnessed  a  very  sudden  death  from  this  very  cause :  care 
should,  therefore,  be  taken  to  guard  against  it. 

It  becomes,  on  this  account,  a  matter  of  much  importance  to 
diminish  this  fetor,  both  mechanically  and  chemically:  mecha- 
nically, by  frequent  washings  with  warm  water,  or  the  flaxseed 
tea ;  and  chemically,  1st,  by  carbonic  acid  gas ;  2d.  by  lime ; 
3d.  by  the  pyroligneous  acid;  and,  4th.  by  the  chloride  of  lime, 
or  soda. 

1st.  By  the  carbonic  acid  gas. 

We  have  enabled  several  patients  to  derive  much  comfort,  as 
well  as  temporary  relief,  from  the  extrication  of  this  gas  within 
the  cavity  of  the  vagina,  by  means  of  a  flexible  tube  of  sufficient 
length  and  size,  attached  to  the  mouth  of  a  bottle,  in  which  there 
is  mixed  diluted  sulphuric  acid,  and  the  carbonate  of  lime.  This 
may  be  introduced  into  the  vagina  several  times  in  the  twenty- 
four  hours.  In  two  or  three  instances,  this  substance  has  relieved 
the  severity  of  pain  whenever  it  was  employed,  as  well  as  di- 
minished the  offensiveness  of  the  discharge. 

2d.  By  lime. 

Lime  may  be  usefully  employed  in  two  ways ;  and  both  may 
be  used  at  the  same  time.  First,  lime  water,  a  little  warmed, 
may  be  thrown  up  the  vagina  by  the  syringe,  several  times  a 
day.  One  of  the  best  forms  we  have  tried  is,  where  a  portion 
of  quicklime  is  slaked  in  an  infusion  of  chamomile  flowers,  and 
permitted  to  settle  clear  before  using  it.  The  second  is,  by 
placing  the  caustic  lime  in  various  parts  of  the  room,  or  even 
under  the  bed-clothes.  For  this  purpose,  it  should  be  broken 
up  into  small  portions,  and  renewed  every  two  or  three  days,  or 
so  often  as  it  is  perceived  to  slack. 

3d.  By  the  pyroligneous  acid. 

The  defecating  power  of  this  acid  is  no  less  certain  than  sur- 
prising; and  for  the  purposes  now  in  view,  is  one  of  the  most 
valuable  articles  of  the  materia  medica.  This  substance,  like  the 
lime,  may  be  used  in  two  ways.  First,  as  an  injection,  in  weak 
solution;  we  cannot  give  any  exact  directions  for  its  strength, 
since  it  varies,  as  do  the  feelings  of  different  patients,  and  even 
of  the  same  patient  at  different  times.  It  should  at  first  be  made 


TREATMENT    OF    CARCINOMA    UTERI. 

very  weak,  and  used  warm,  as  directed  for  the  other  injections ; 
its  strength  must  be  increased  as  the  feelings  of  the  patient  may 
permit;  remembering,  the  stronger  it  can  be  used,  the  more  cer- 
tain is  its  control  over  the  putrid  exhalations.  It  may,  at  the 
same  time,  be  used  in  its  concentrated  form,  by  wetting  a  folded 
towel  with  it,  and  placing  it  over  the  external  parts — this  is  to 
be  renewed  when  dry.  The  cheapness  of  this  article  enables 
the  patient  to  indulge  in  a  liberal  use  of  it. 

4th.  By  the  chloride  of  lime  or  of  soda  in  solution,  as  an  in- 
jection per  vaginam,  beginning  with  a  feeble  solution,  (a  drachm 
of  either  to  the  pound  of  water,)  and  gradually  increasing  the 
proportions  as  the  parts  may  become  accustomed  to  the  applica- 
tion. 

5.  By  rest. 

Rest  is  a  sine  qua  non  in  this  complaint ;  whether  it  be  in  its 
incipient  stage,  or  at  a  more  advanced  period  of  its  progress.  But 
by  rest,  do  not  let  us  be  understood  to  mean  absolute  confinement 
to  bed.  By  rest,  we  mean  the  indulgence  of  a  horizontal  posi- 
tion for  the  body,  without  intervening  exercise.  This  auxiliary 
acts  by  equalizing  the  circulation ;  by  diminishing  its  force ;  by 
abstracting  the  stimulus  of  motion ;  by  preventing  the  conse- 
quences of  the  pressure  of  the  abdominal  viscera  upon  the  fundus 
of  the  uterus,  and  thus  avoid  irritating  the  cervix ;  and  in  cases 
where  hemorrhage  attends,  by  permitting  the  coagula,  which 
arrests  for  the  time  the  bleeding,  to  remain  undisturbed;  thus 
preventing  the  renewal  of  it. 

It  may  be  well  to  caution  the  young  practitioner  against  too 
much  anxiety  for  the  occasional  discharges  of  blood,  which  are 
almost  sure  to  take  place,  sooner  or  later,  in  this  disease;  he 
should  regard  them  for  a  time  as  so  many  leechings,  from  which 
the  patient  derives  much  immediate  comfort,  if  not  eventual 
benefit. 

Upon  the  same  principle,  he  should  not  attempt  to  arrest  the 
purulent  discharge  from  the  vagina,  by  the  employment  of  astrin- 
gent or  stimulating  injections.  We  have  already  directed  strict 
attention  to  cleanliness,  by  means  of  simple  warm  water:  Avith 
this,  there  can  be  no  fear  of  doing  mischief  by  any  stimulating 
property.  But  medicated  injections  of  an  astringent  nature, 
must  be  forbidden;  unless  it  may  be  the  occasional  use  of  a  very 
weak  solution  of  the  acetate  of  lead — from  this  injection  we  have 
thought  advantage  was  derived  by  its  sedative  influence,  to  the 
irritable  neck  of  the  uterus.  Tonics  are  ever  inadmissible  in 
this  complaint. 

,  Mr.  Clarke  concludes  his  remarks  on  the  treatment  of  this  dis- 
ease by  observing,  "In  treating  this  disease,  as  no  cure  is  known 


TREATMENT   OF    CARCINOMA    UTERI.  253 

for  it,  the  practitioner  must  be  satisfied  with  palliatives,  and  not 
be  anxious  to  restore  the  vigour  of  the  body,  which  might  aggra- 
vate the  disease  again.  Still,  let  it  be  remembered,  that,  by  a 
strict  attention  to  management,  and  an  unwearied  perseverance 
in  the  means  suggested,  all  the  cases  of  the  disease  may  be 
relieved;  in  many,  the  farther  enlargement  of  the  tumour,  or 
progress  of  the  thickening,  may  be  prevented;  and  if  the  author 
was  not  afraid  of  deceiving  himself,  or  of  deceiving  others,  he 
would  venture  to  express  a  belief,  that  in  a  few  instances,  the 
disease  has  altogether  subsided,"  p.  235. 

The  consolation  which  this  last  suggestion  affords  should  be 
constantly  kept  in  mind ;  as  it  holds  out  a  strong  inducement  to 
both  patient  and  practitioner,  to  persevere  in  the  use  of  the  reme- 
dies pointed  out ;  shows  that  this  formidable  and  loathsome  dis- 
ease may  occasionally  be  prevented  from  running  its  terrible 
career;  and  restores  a  useful  individual  to  society.  We  are 
equally  persuaded  with  Mr.  Clarke,  that  in  instances  of  the  en- 
largements under  consideration,  we  have  succeeded  in  entirely 
removing  them  by  the  plan  laid  down.  And  farther,  that,  from 
the  success  of  such  cases,  strong  inducements  are  held  out  to 
the  timid  sex  to  make  known,  at  an  early  period,  any  unpleasant 
feelings  they  may  experience  in  these  parts,  that  the  fairest 
chance  may  be  given  to  perseverance  in  proper  and  well-devised 
remedies.  And  to  the  practitioner,  it  offers  an  inducement  to 
exertion  in  the  cause  of  humanity. 

For  the  most  part,  after  ulceration  has  commenced,  the  patient 
suffers  much  from  the  violence  and  peculiarity  of  the  pain,  which 
now  is  almost  sure  to  attend.  This  is  so  constant,  especially  at 
night,  as  to  deprive  her  almost  altogether  of  rest.  There  is  no 
alternative  now,  but  the  employment  of  opium,  or  other  narcotics, 
which  but  too  soon  lose  their  influence,  however  we  may  attempt 
to  maintain  it  by  increasing  the  dose ;  and  the  patient  thus  early 
becomes  deprived  of  the  only  solace  art  can  give  her. 

But  in  this  state  of  carcinoma,  the  same  regard  must  be  paid 
to  the  general  state  of  the  system,  as  in  its  first  stage.  For, 
notwithstanding  absorption  has  commenced,  and  ulceration  is 
progressing,  the  system  becomes  implicated,  and  the  arteries  are 
found  to  be  much  excited.  A  high  sympathetic  fever  is  produced, 
accompanied  by  a  hot  dry  skin,  and  almost  insatiable  thirst,  to- 
gether with  a  sense  of  intense  heat  in  the  stomach  itself.  This 
burning  aggravates  all  the  other  symptoms,  by  its  intensity  and 
pertinacity:  sleep  is  interrupted,  and  the  patient  will  sometimes 
almost  starve,  rather  than  take  food  at  the  risk  of  increasing 
this  sensation.  This  feeling  sometimes  proceeds  from  acidity; 
when  this  is  the  case,  absorbents  or  antacids  should  be  given ; 
and  the  frequent  use  of  small  quantities  of  good  sweet  cream,  is 
almost  sure  to  afford  at  least  temporary  ease. 


254  TREATMENT    OF    CARCINOMA    UTERI. 

The  pulse  under  these  circumstances,  is  always,  we  believe, 
excited ;  and  in  a  degree  that  requires  the  loss  of  blood,  either 
from  the  arm,  or  from  near  the  part.  Some  may  entertain  fears 
of  this  remedy  from  the  appearance  of  weakness  which  the  pa- 
tient discovers ;  but  this  must  not  create  alarm ;  for  the  state  of 
the  system  declares  its  propriety.  Indeed,  nature  seems  to  offer 
this  relief,  by  producing  a  hemorrhage  from  the  part,  which 
hardly  ever  fails  to  afford  it.  Besides,  it  is  sure  to  place  the 
system  in  a  more  favourable  condition  for  the  operation  of  nar- 
cotics, to  which,  at  this  stage  of  the  disease,  we  must  always 
have  recourse ;  and  happy  is  the  patient,  when  she  can  obtain  a 
truce  to  suffering,  by  their  agency ;  for  the  pain  is  generally  so 
severe  and  protracted,  as  to  quickly  destroy  their  power.  For 
this  purpose,  we  believe  it  will  be  found  that  opium,  in  one  form 
or  other,  is  the  only  one  that  can  be  relied  upon  for  any  length 
of  time  together. 

Much,  however,  has  been  said  in  praise  of  several  other  nar- 
cotics, besides  opium,  in  the  disease  in  question;  such  as  the 
belladonna,  the  hyosciamus,  the  stramonium,  and  the  hemlock. 
We  are  sorry  we  cannot  add  any  testimony  in  their  favour.  In 
our  hands  they  have  fallen  far  short  of  the  anodyne  powers  of 
the  opium ;  and  have  constantly  failed  to  merit  the  high  enco- 
miums which  have  been  bestowed  upon  them. 

I  am  happy  to  find  myself  supported  in  this  experience,  by 
Dr.  Chauffard.1  After  pointing  out  the  great  abuses  committed 
by  persisting  a  long  time  in  the  use  of  narcotics,  he  observes, 
"  The  violence  of  pain  often  forces  us  to  the  administration  of 
narcotics :  but  do  not  let  us  forget,  that  in  such  cases,  two  or 
three  grains  of  opium  will  succeed  better  to  calm  it,  than  forty 
grains  of  the  other  extracts.  I  have  seen  eight  grains  of  opium, 
in  a  terrible  cancer,  afford  more  complete  comfort  or  relief,  than 
two  drachms  of  the  extract  of  aconite,  and  this  without  worrying 
the  digestive  organs  or  disturbing  the  intellectual  faculties  in  any 
like  degree:  and  also  much  more  promptly.  This  substance, 
(opium,)  would  procure  some  moments  of  refreshing  sleep,  which 
could  not  be  obtained  from  the  other."  This  is  truly  a  matter 
of  regret ;  as  it  abridges  our  resources  at  a  period  when  so  few 
can  be  commanded,  yet  when  so  many  are  required. 

So  frequent  and  so  uniform  have  been  our  disappointments, 
that  we  neither  consider  the  belladonna,  hyosciamus,  stramonium, 
nor  the  hemlock,  as  substitutes  for  opium.  And  though  alto- 
gether aware  how  unfriendly  some  of  its  properties  are  to  many 
constitutions,  yet  we  cannot,  as  a  general  remedy,  give  it  up  for 
any  other,  with  which  we  are  acquainted. 

Every  preparation  of  opium  is  not  equally  objectionable;  the 

1  Memoire  sur  1'emploi  et  Tabus  des  medicaments  stupefiants  les  plus  usites. — 
Trans.  Med.  &c.  for  July,  1830. 


TREATMENT    OF    CARCINOMA    UTEKI.  255 

I 

common  laudanum  is,  perhaps,  the  most  so  of  any;  even  more 
so  than  in  its  solid  form.  The  least,  (if  we  except  morphia,)  is 
the  acetated  tincture  of  this  drug ;  or  what  is  commonly  called 
"  the  black  drop."  In  this  form,  several  of  its  unfriendly  ten- 
dencies are  obviated  altogether;  and  almost  always,  are  very 
much  diminished.  It  is  seldom  followed  by  headache  or  nausea  ; 
nor  does  it  constipate  the  bowels,  in  any  like  degree,  as  the  lau- 
danum. It,  therefore,  always  merits  the  preference,  when  it 
can  be  commanded ;  and  when  it  cannot,  much  of  the  inconve- 
nience of  the  laudanum  may  be  avoided,  by  mixing  the  dose  with 
sweetened  vinegar ;  or  by  the  addition  of  a  few  grains  of  the 
carbonate  of  soda  or  potash.1 

It  has  been  a  usual  practice  in  carcinoma,  to  give  the  cicuta 
in  increasing  doses.  We  have  thought  that  we  have  sometimes 
derived  a  temporary  benefit,  but  we  have  never  witnessed  a 
permanent  advantage  from  it,  to  whatever  extent  we  have  car- 
ried it.  We  have  thought,  however,  that  opium  was  more  cer- 
tain to  give  relief  from  pain,  while  the  patient  was  using  the, 
hemlock,  than  when  she  was  not  under  its  influence. 

We  have  frequently  found,  in  the  same  patient,  that  opium 
would  procure  rest  at  one  time  much  more  certainly  than  at 
another,  even  under  the  same  circumstances,  as  far  as  could  be 
determined.  Why  this  has  happened,  we  cannot  pretend  to  say ; 
but  when  opium  has  failed,  we  have  found  that  camphor,  in  liberal 
doses,  would  oftentimes  succeed.  Indeed,  we  have  several  times 
found  that  the  camphor  was  a  valuable  addition  to  our  slender 
means  of  procuring  rest,  in  cases  of  severe  pain  from  ulcerated 
carcinoma ;  and  this  especially  where  opium  disagreed,  or  had 
worn  itself  out.  We  have  also,  in  several  instances,  found  that 
the  spirit  of  turpentine,  in  twenty  drop  doses,  has  also  procured 
sleep,  when  it  could  not  be  obtained  by  opium.  The  same  may 
be  said  of  the  liq.  anod.  Hoffm.  in  tea-spoonful  doses.8 

When  opium  either  disagrees,  or  its  efficacy  is  waning,  giving 
it  in  the  form  of  an  enema,  has  very  often  a  most  happy  effect. 
When  employed  in  this  way,  a  treble  dose  of  the  laudanum,  in 
two  ounces  of  warm  water,  should  be  given  at  a  time ;  and  re- 
peated, pro  re  nata. 

1  Since  the  above  was  written,  we  have  become  possessed  of  a  preparation  of 
opium  that  bids  fair  to  supersede  almost  all  the  others;  namely,  the  "  denarco- 
tized  laudanum."  This  is  prepared  from  opium,  that  has  been  divested  of  its 
narcotine.  It  sits  most  kindly  upon  the  stomach;  and  is  very  rarely  followed  by 
the  after  consequences  of  the  common  laudanum,  even  in  those  who  are  generally 
obnoxious  to  them.  Morphia  itself  offers  a  valuable  resource;  it  is  very  certain 
in  its  effects,  and  is  not  usually  followed  by  the  inconveniences  of  the  other  prepa- 
rations. It  may  be  given  either  in  substance  or  in  solution;  one-sixth  of  a  grain 
is  about  equal  to  one  grain  of  opium,  or  thirty  drops  of  laudanum. 

a  Care  should  always  be  taken  that  this  substance  has  been  faithfully  prepared, 
See  note  to  page  217. 


256  TREATMENT    OF    CARCINOMA    UTERI. 

When  the  stomach  becomes  affected,  the  case  is  always  more 
deplorable,  for  reasons  easily  imagined.  This  rarely  takes  place, 
as  a  sympathetic  affection,  until  ulceration  has  commenced ;  and 
when  it  does,  it  goes  on,  pari  passu,  with  the  ulceration,  and  be- 
comes even  more  distressing  sometimes,  than  the  original  com- 
plaint. 

We  have  but  a  sorry  choice  of  evils,  "when  this  condition  of 
the  stomach  exists;  for  we  are  generally  obliged  to  give  up  a 
system  of  diet,  which  is  best  calculated  to  mitigate  the  uterine 
sufferings,  for  one  which  is  better  adapted  to  appease  a  rebellious 
stomach.  We  must  give  up  the  vegetable  course  of  diet,  for  one 
of  animal  substances,  that  we  may  tranquillize  this  organ ;  and 
we  must  also  neutralize  the  predominating  acid,  by  the  various 
antacids,  or  by  the  sulphuric,  or  nitro-muriatic  acid,  in  small, 
but  often  repeated  doses. 

One  of  the  best  sitting  substances  that  we  have  found,  when 
the  stomach  is  extremely  irritable,  is  rich  sweet  cream ;  this  must 
be  given  by  the  tea-spoonful ;  and  repeated  every  fifteen  or  twenty 
minutes. 

We  shall  conclude  this  account  of  carcinoma,  with  giving  an 
extract  from  Mr.  Clarke's  work,  so  often  mentioned.  We  do 
this,  because  his  remarks  upon  this  terrible  disease  are  judicious, 
and  bespeak  the  experienced  practitioner,  as  well  as  the  man  of 
feeling.  Moreover,  there  are  some  views  of  the  disease  which 
are  novel,  and  a  part  of  practice  and  resources,  that  is  not  suf- 
ficiently familiar  to  the  American  practitioner.  We  have  pre- 
ferred giving  his  opinions  and  suggestions  in  his  own  language, 
to  condensing  them,  though  at  the  risk  of  being  blamed  for  so 
long  a  quotation,  by  those  who  have  not  yet  met  with  the  dis- 
ease. But,  from  the  practitioner  who  may  have  such  a  case  in 
hand,  and  whose  resources  are  nearly  exhausted,  we  fear  no  such 
censure :  on  the  contrary,  we  are  sure  we  shall  receive  his  thanks 
for  any  new  suggestion  that  will,  for  even  an  hour,  relieve  his 
suffering  patient. 

"  The  management  of  the  discharge  from  carcinomatous  sores, 
is  a  circumstance  deserving  the  best  attention  of  the  surgeon. 
This  discharge  appears  to  have  the  power  of  converting  the  neigh- 
bouring parts,  to  which  it  is  applied,  in  some  instances,  into  sores 
of  a  similar  character  to  that  by  which  it  was  itself  secreted : 
and  there  is  reason  to  believe,  that  the  spreading  of  carcinomatous 
ulceration  may  be  greatly  retarded  by  the  employment  of  those 
substances  which  absorb  or  remove  the  ichorous  fluid  secreted  by 
them.  Common  aphthous  sores,  which  frequently  arise  in  the 
vestibulum  of  women,  who  have  long  laboured  under  diseases  of 
the  female  organs,  may  also  possibly  be  converted  into  malignant 
ulcerations.  These  observations  especially  apply  to  carcinoma- 
tous ulcerations  of  the  internal  parts,  in  which  the  discharges  are 


TREATMENT    OF    CARCINOMA    UTERI.  257 

more  likely  to  be  retained,  than  where  the  disease  attacks  ex- 
ternal surfaces.  If  it  were  only  that  the  foetor  attending  such 
sores  would  be  removed  by  cleanliness,  attention  to  this  circum- 
stance would  be  of  great  consequence,  inasmuch  as  the  patient's 
health,  and  that  of  such  persons  as  may  associate  with  her,  will 
be  less  likely  to  suffer,  than  when  constantly  breathing  an  impure 
atmosphere. 

"  Of  all  the  modes  of  applying  water  to  sores  at  the  upper  part 
of  the  vagina,  none  is  so  effectual  as  the  use  of  the  hip-bath ;  in 
the  employment  of  which,  the  water  is  brought  into  contact  with 
the  sore  without  any  risk  of  infusing  the  latter.    By  these  means, 
the  object  of  maintaining  cleanliness  is  not  only  obtained,  but  a 
soothing  application  is  made  to  an  irritable  surface ;  the  carefully 
injecting  warm  water  into  the  vagina,  by  a  syringe,  or  the  agi- 
tating the  water  with  the  hand,  will  render  it  more  likely  to  remove 
any  portions  of  coagulating  lymph,  or  thickening  matter,  which 
may  adhere  to  the  inside  'of  the  vagina.     The  heat  of  the  water 
employed  should  depend  upon  the  feelings  of  the  patient  in  some 
measure ;  but,  generally  speaking,  it  may  vary  from  about  eighty- 
six  to  ninety-four  degrees.     Where  the  patient  is  too  weak  to 
bear  the  exertion  of  being  put  into  a  hip-bath,  her  hips  may  be 
brought  over  the  edge  of  the  bed,  and  warm  water  may  be  care- 
fully injected  into  the  vagina  by  a  small  syringe.     The  quantity 
of  the  discharge  is  frequently  increased  by  the  means  above-men- 
tioned, but  the  comfort  which  the  patient  will  derive  from  it  will 
abundantly  compensate  her  for  any  debility  which  may  be  pro- 
duced by  the  remedy;  and  excruciating  attacks  of  pain  are  some- 
times rendered  very  sufferable  by  a  frequent  recurrence  to  it. 
Strong  decoction  of  carrots,  sometimes  used  for  the  same  purpose, 
has  the  happiest  effects.     Warm  water  may  also  be  made  the 
vehicle  for  a  variety  of  sedative  applications,  which  are  found  by 
experience  to  tranquillize  all  irritable  sores ;  and,  in  some,  to  ex- 
pedite the  healing  process.     Amongst  the  different  applications 
for  this  purpose,  the  extractum  conii,  or  extractum  hyosciami, 
maybe  mentioned,  either  of  which  may  be  employed  in  the  pro- 
portion of  about  three  or  four  drachms  to  a  pint  of  water.     Solu- 
tions of  opium,  or  of  extract  of  poppy,  may  also  be  used ;  of  the 
former,  two  drachms ;  of  the  latter,  half  an  ounce  may  be  dis- 
solved in  each  pint  of  water.     Starch  or  mucilage  of  quince-seed, 
form  good  menstrua  for  these  applications;  their  adhesive  pro- 
perty enabling  them  to  cling  to  surfaces  to  which  they  are  applied. 
Three  or  four  ounces  of  either  of  these  fluids,  impregnated  with 
sedative  substances,  may  be  thrown  into  the  rectum,  in  those 
cases  where  relief  is  not  obtained  by  their  application  to  the  va- 
gina; but  when  opium  is  used  for  this  purpose,  the  practitioner 
should  be  very  careful  to  watch  over  its  effects,  as*  it  has  some- 
times happened  that  unpleasant  consequences  have  arisen  from 
17 


258  TREATMENT    OF    CARCINOMA    UTERI. 

the  application  of  this  drug  to  the  rectum,  such  as  vomiting, 
syncope,  cold  extremities,  and  irregularity  of  circulation.  The 
action  of  the  absorbents  of  the  rectum  is,  in  all  probability,  in 
these  cases,  increased  by  the  inflammatory  process  which  exists 
in  the  vicinity ;  besides  which,  the  action  of  the  rectum  itself  is 
temporarily  taken  off,  so  that  the  enema  will  probably  be  retained 
during  a  considerable  length  of  time.  Plasters  and  liniments,  into 
the  composition  of  which  opium  enters  largely,  will  sometimes 
be  found  serviceable  in  allaying  pain,  and  are  useful  auxiliaries 
in  a  disease,  in  which  all  the  resources  of  the  practitioner  may 
be  required  to  diminish  the  sufferings  of  the  patient. 

"  There  are  some  applications  which  produce  a  sedative  or  a 
stimulating  effect,  according  to  the  strength  of  which  they  are 
used.  A  very  diluted  mixture  of  acetic  acid,  or  of  nitric  acid  in 
water,  will  form  a  soothing  application  to  an  irritable  part,  whilst, 
in  different  proportions,  they  will  become  highly  irritating. 
Either  of  the  lotions  mentioned  beneath  may  be  employed. 

R.  Acidi  acetici,     -    ...    ^ss. 

Aquse  distillatae,    -    -    -    Oj. — M.f.  injectio. 

Or, 
R.  Acidi  nitrici,     -    -    -     -    gutt.  x. 

Aquae  distillatae,     -    -    -     Oj. — M.  f.  injectio. 

Or, 

R.  Liquoris  plumbi  acetatis,'   3j. 
Acidi  acetici,     ....    gii. 
Sp.  Vinosi.    -----    3J. 
Aquse  distillate,     -    -    -    §xvss. — M.  f.  injectio. 

"  If  the  discharge  should  become  so  profuse  as  to  induce  great 
debility,  injections  which  possess  an  astringent  power  must  be 
sought  for. 

R.  Decocti  corticis  granati,    -    Oj. 

Sulphatis  aluminse,       -    -    gss. — M.  f.  injectio. 

Or, 

R.  Zinci  sulphatis,  -  -  -  gss. 
Aquae  distillatse,  -  -  -  3jxv. 
Tinct.  RLao.  -  -  -  -  |j. — M.  f.  injectio. 

"If  the  discharge  should  assume  a  sanguineous  appearance,  it 
should  be  considered  how  far  it  would  be  safe  to  permit  its  con- 
tinuance. If  the  patient  should  be  in  great  pain  at  the  time,  it 
may  be  right  not  to  restrain  it  hastily,  unless  the  patient's  strength 
should  have  been  previously  much  exhausted ;  but  if  it  should 
appear  desirable  to  diminish  the  hemorrhage,  the  astringents 
which  have  been  before  recommended,  may  be  employed,  and 
their  strength  may  be  increased,  or  the  following  may  be  em- 
ployed in  their  stead : — 


TREATMENT   OF   CARCINOMA   UTEKI.  259 

R.  Argenti  nitratis,    -    i'^'^  .    gr.  x. 
Aquae  distillatse,    .....     Oi. — M. 

Or, 

R.  Cupri  sulphatis, gss. 

Decocti  cinchonse,     ....    Oi. — M. 

tfi'y:    '"sii'.v-.i'i  '•:>.'[  ut '*  .!»>»>> ;vrLi<j  .-.    ?*;'*?.«     ;-V;J-H» {»•.'••»!  .{ioi-'i.* '; 

"  Respecting  internal  remedies,  although  no  one  has  as  yet 
discovered  any  medicine  capable  of  removing  the  disease,  it  may 
not  be  too  much  to  state,  that  there  is  scarcely  a  medicine  of  any 
class  which  may  not,  in  some  way  or  other,  or  at  some  period  or 
other,  be  useful  in  this  complaint.  Various  are  the  symptoms 
which  may  arise ;  various  must  be  the  means  of  obviating  them ; 
and  he  will  be  the  best  practitioner,  who  best  understands  the 
adaptation  of  these  means  to  their  end.  To  point  them  out  here, 
would  be  an  endless  labour,  and  a  waste  of  the  reader's  time. 

"  It  may  be  sufficient  to  observe  that  the  patient  should  be 
treated  upon  general  principles,  bearing  in  mind,  on  the  one 
hand,  the  hitherto  intractable  nature  of  the  malady,  and  on  the 
other,  the  sufferings  of  humanity,  which  call  loudly  for  relief. 

"Pain,  the  great  evil  of  life,  is  the  symptom  by  which  the  pa- 
tient will  be  most  distressed;  and,  happily,  in  the  sedative 
class  of  medicines,  there  are  to  be  found  many  capable  of  re- 
lieving it. 

"  It  should  be  a  rule  of  practice,  never  to  exhibit  a  sedative  of 
great  power,  when  a  milder  will  produce  equal  relief;  because 
the  disease  is  one  of  long  duration,  of  increasing  suffering,  and 
every  medicine  will  at  length  fail  in  producing  its  effect. 

"  Hyosciamus  and  conium  may  be  amongst  the  first  employed, 
and  the  dose  of  each  may  vary  from  three  to  eight,  or  ten  grains. 
Larger  doses  have  been  exhibited ;  but  the  object  is  not  to  know 
how  much  of  these  or  of  any  other  drug  can  be  taken  with  im- 
punity, but  how  much  is  necessary  to  produce  the  desired  effect. 
If  they  are  wantonly  employed,  the  patient  will  be  exposed  to 
another  set  of  symptoms,  arising  from  a  disturbed  state  of  the 
stomach,  and  of  the  brain ;  as  flatulence,  heartburn,  eructations, 
delirium :  the  necessity  for  the  exhibition  of  these  medicines,  must 
regulate  not  only  their  dose,  but  the  frequency  of  their  exhibition. 

"Extractum  stramonii  is  another  serviceable  remedy  in  allay- 
ing pain,  and  it  may  be  given  in  doses  of  a  grain. 

"The  writer  is  not  in  the  habit  of  exhibiting  belladonna, 
having  once  seen  a  patient  nearly  destroyed  by  two  small  doses 
of  it.  Other  practitioners,  however,  have  employed  it,  it  is  said, 
with  advantage.  Mr.  Brodie  has  informed  the  writer,  that  he 
has  seen  the  happiest  effects  produced  by  a  suppository  contain- 
ing extractae  belladonnas,  gr.  j.  in  cases  of  irritable  bladder,  and 
also  of  carcinoma  of  the  rectum.  Perhaps,  therefore,  in  those 
instances  in  which  the  administration  of  other  sedatives  is  un- 


260  POLYPUS   OF   THE  UTERUS. 

availing,  it  may  be  advisable  to  administer  the  above  medicine 
in  the  form  alluded  to. 

"  As  the  symptoms  become  more  pressing,  and  as  the  sufferings 
of  the  patient  increase,  still  there  will  remain  to  the  practitioner 
one  resource,  and  to  the  patient  one  solace,  in  opium,  by  means 
of  which,  her  distresses  may  be  alleviated,  and  her  passage  from 
this  world  to  another  rendered  less  agonizing.  It  will  not  be 
sufficient  simply  to  prescribe  a  dose  of  opium,  at  stated  intervals ; 
that  dose  must  be  proportioned  to  the  necessity  for  its  use;  and 
the  skilful  combination  of  it  with  other  medicines,  and  the  selec- 
tion of  its  different  preparations,  will  call  forth  the  happiest  efforts 
of  the  practitioner:  in  one  case  opium  in  a  solid  form  will  be 
found  to  agree;  in  another  the  tinctura  opii  of  the  pharmacopoeia 
will  better  answer  the  purpose;  in  the  third,  the  preparation 
known  by  the  name  of  black  drop ;  in  a  fourth,  the  liquor  opii 
sedatives  of  Mr.  Beattie,  will  quiet  the  patient,  and  at  the  same 
time  produce  the  least  disturbance  in  the  system ;  whilst  the  irri- 
table state  into  which  some  patients  fall,  will  be  most  successfully 
•diminished  by  the  very  small  quantity  of  opium  which  enters  into 
the  composition  of  the  tinctura  camphorse  composita. 

"In  the  greater  number  of  painful  diseases,  which  call  for  the 
use  of  opium,  less  care  is  required ;  but  the  sympathy  of  the  sto- 
mach is  so  actively  called  forth,  when  the  uterus  is  the  seat  of 
this  disease,  that  it  will  be  capriciously  inclined  towards  one  me- 
dicine, whilst  it  receives  another  with  great  comfort  and  advan- 
tage. If,  as  always  happens  towards  the  close  of  ulcerated  carci- 
noma of  the  uterus,  vomiting  should  come  on,  the  combination  of 
spices  with  opium,  will  render  this  medicine  more  agreeable  to 
the  stomach.  The  julepum  menthae,  cinnamon  water,  and,  in 
some  cases  weak  brandy  and  water,  will  form  the  best  vehicles 
for  the  different  preparations  of  opium ;  sometimes  a  mixture  of 
confeetio  opiatae  and  spiritus  setheris  sulphurici  compositus,  given 
in  peppermint  water,  in  small  doses,  at  short  intervals,  will  re- 
lieve, in  an  expeditious  and  certain  manner,  the  vomiting,  sin- 
gultus,  and  eructation,  more  effectually  than  any  other  combina- 
tions of  medicines." 


SECT.  III. — Of  the  Polypus  of  the  Uterus, 
This  disease  of  the  uterus  the  author  has  never  seen  j1  he  is 

1  Since  the  period  stated  above,  I  have  seen  several  cases  of  "  polypus  of  the 

uterus,"  one  of  which  was  fatal.     Mrs. ,  aged  forty-five  years,  was  attacked 

with  pains  resembling  labour.  After  they  had  continued  with  more  or  less  seve- 
rity for  thirty-six  hours,  I  was  requested  to  visit  her.  I  found  her  labouring  un- 
der powerful  pains,  which  were  almost  without  intermission,  and  of  great  force. 
I  immediately  examined  per  vaginam,  and  found  a  tumour  of  the  size  of  a  child's 


* 


POLYPUS   OF   THE    UTERUS.  261 

therefore  under  the  necessity  of  drawing  his  account  of  the  poly- 
pus from  the  experience  of  others.  He  has  endeavoured  to  give 
a  faithful  history  of  this  complaint,  by  consulting  those  he  esteems 
to  be  the  best  authorities  upon  this  subject;  namely,  Levret, 
Denman,  and  Clark. 

It  would  seem  to  be  fairly  presumable,  that  this  disease  is  of 
more  rare  occurrence  in  this  country,  than  in  Europe;  since,  in 
the  practice  of  the  gentlemen  just  named,  many  cases  have  oc- 
curred ;  while  in  this,  the  experience  of  a  number  of  gentlemen 
whom  I  have  consulted  has  not  furnished  one.  This  would  also 
seem  to  call  in  doubt  one  of  the  causes  assigned  for  the  produc- 
tion of  this  disease;  namely,  injuries  which  the  uterus  may  have 
sustained  during  labour;  for  it  is  to  be  presumed,  that  were  this 
a  common  cause,  the  American  women  would  have  a  greater 
claim  to  polypi,  than  they  appear  to  have. 

Dr.  Denman  says,  "The  cause  of  polypi  is  supposed  to  be 
some  accidental  injury  done  to  the  part  at  the  time  of  labour  or 
otherwise;  but  more  commonly,  it  is  a  spontaneous  disease,  pro- 
ceeding from  a  certain  disposition  of  the  constitution,  or  of  the 
part  itself;  as  those  who  have  a  polypus  of  the  uterus  are  apt 
to  have  excrescences  from  other  parts ;  and  they  sometimes  exist 
in  those  who  have  never  been  pregnant,  and  even  in  virgins." — 
Introd.  Francis'  Ed.  p.  123. 

Mr.  Clarke  defines  polypus  to  be  an  "insensible  tumour  at- 
tached to  the  internal  part  of  the  uterus,  by  a  small  neck,  forming 
a  disease  of  a  very  important  character,"  p.  243,  vol.  i.  This 
definition  does  not  exactly  correspond  with  the  history  given  of 
this  complaint  by  Dr.  Denman:  he  says,  "Some  of  them  hang 
by  a  small  pedicle,  and  others  have  a  broad  basis,  especially  at 
their  commencement,"1  p.  123.  Nor  is  it  so  satisfactory  as  the 

head  at  seven  months,  occupying,  or  rather  advancing  through  the  vagina.  Sus- 
pecting the  nature  of  the  tumour,  and  fearing  it  would  invert  the  uterus  if  it  did 
escape  from  the  os  externum,  I  opposed  its  passage,  with  all  the  strength  I  could 
make  to  bear  upon  the  part,  but  without  success,  for  in  defiance  of  all  opposition, 
the  tumour  was  pushed  without  the  vulva.  It  was  attached  to  the  uterus  by  a 
short  neck,  and  the  tumour  had  inverted  this  organ  upon  its  escaping  from  the 
vagina.  I  endeavoured  to  restore  the  mass,  but  without  success,  as  the  parts 
were  so  extremely  sensible,  that  the  woman  could  scarcely  endure  the  slightest 
touch.  The  tumour  soon  became  black,  and  very  offensive;  the  woman  had  been 
exhausted  by  a  long-continued  discharge  of  blood  of  some  months'  standing,  to- 
gether with  a  considerable  hemorrhage  during  the  effort  the  uterus  made  to  dis- 
lodge the  tumour :  she  died  the  next  day.  Leave  could  not  be  obtained  to  examine 
the  body,  as  it  was  in  extremely  hot  weather,  and  was  to  be  removed  some  dis- 
tance into  the  country. 

1  A  lady  from  Savannah,  Qeorgia,  consulted  me  for  a  polypus  of  the  uterus,  in 
July,  1830.  Upon  examination,  it  proved  to  be  small,  and  its  pedicle  very  slim. 
It  was  seized  by  two  fingers  and  the  thumb,  and  drawn  down  to  the  os  externum  : 
in  doing  this  the  tumour  separated  at  its  attachment  with  the  uterus — it  caused 
no  pain,  nor  did  the  smallest  hemorrhage  follow.  As  I  have  not  heard  from  the 
lady  since,  I  presume  she  has  suffered  no  farther  inconvenience,  though  she  had 
been  very  much  reduced  previously  by  repeated  hemorrhage  from  this  tumour. 


262  POLYPUS    OF    THE   UTERUS. 

definition  of  Levret :  he  makes  it  "an  indolent  circumscribed 
tumour,  more,  or  less  salient,  resembling  a  fleshy  or  fungous  ex- 
crescence, covered  by  the  membrane  from  which  it  takes  its  rise, 
and  which  is  of  greater  or  less  thickness." — Obser.  sur  la  Cure 
radical  de  plusiers  Poly,  de  la  Matrice,  &c.,  p.  2. 

Levret  makes  three  species  of  uterine  polypi:  but  this  is  cer- 
tainly an  unnecessary  distinction,  since  his  species  are  derived 
from  the  situation  of  the  polypus  in  the  uterus,  and  not  from  a 
difference  in  their  organization ;  therefore,  properly  speaking,  it 
is  a  mere  difference  of  location.  He  says  his  first  species,  which 
he  declares  at  the  same  time  to  be  the  most  common,  has  its 
origin  or  attachment  from  the  fundus  of  the  uterus ;  the  second, 
which  is  less  frequent,  takes  its  origin  from  the  neck  of  this 
organ ;  and  the  third,  which  is  the  most  rare,  has  its  pedicle 
attached  to  the  margin  of  the  orifice  of  the  uterus,  p.  14.  He 
has  given  plates  to  prove  the  different  locations  of  these  tumours, 
which  we  have  copied.  See  Plate  IV. 

These  substances  are  vascular  in  different  degrees;  and, 
agreeably  to  Levret,  the  veins  are  large  in  proportion  to  the 
arteries.  The  latter  become  varicose  in  that  species  which  is 
confined  within  the  cavity  of  the  uterus,  or  has  its  origin  from 
its  fundus. 

The  first  species  of  Levret  is  always  attended,  at  a  certain 
period,  by  hemorrhage;  and  is  of  course  always  accompanied 
by  an  increase  of  size  of  the  uterus.  A  sense  of  weight,  or 
bearing  down,  is  experienced,  of  more  or  less  intensity,  as  the 
polypus  may  be  large  or  small..  It  is  of  uncertain  size ;  and  may 
employ  a  longer  or  shorter  period  for  such  a  growth  as  shall  be 
either  very  troublesome,  or  strongly  engage  the  woman  in  a  con- 
sideration of  her  situation. 

It  occasionally  grows  very  large,  and  distends  the  uterus  so 
much  that  it  can  be  distinctly  felt  above  the  pubes.  When  it 
acquires  this  volume,  and  oftentimes  before,  there  is  found  a  dis- 
charge from  the  vagina,  which  in  the  commencement  is  serous; 
but  may  soon  become  purulent  and  sanguineous. 

If  a  finger  be  introduced  into  the  vagina,  the  os  uteri  will  be 
found  open  to  an  extent  much  beyond  its  natural  size;  and  will 
permit  the  point  of  the  finger  to  penetrate  the  cavity  of  the 
uterus,  in  which  a  substance  will  be  felt  of  greater  or  less  firm- 
ness, and  of  different  degrees  of  inequality.  The  finger,  if  it  be 
made  to  pass  a  sufficient  distance  within  the  womb,  can  be 
turned  round  the  body,  which  the  uterus  seems  to  enclose. 
This  examination  may  be  followed  by  a  very  small,  or  a  very 
large  flow  of  blood. 

Since  the  above  was  written,  I  have  heard  from  her  husband,  who  assures  me  she 
is  perfectly  well. 


POLYPUS    OF    THE    UTERUS.  263 

The  woman  is  almost  always  troubled  with  a  discharge  of 
blood,  which  at  times  seems  to  assume  a  periodical  movement;  or 
it  may  only  be  more  abundant  at  certain  periods,  while  a  con- 
stant but  moderate  flow  fills  up  the  interval.  Pain  of  a  periodi- 
cal kind  sometimes  ensues;  and  this  may  be  so  long  continued 
and  severe,  as  to  force  the  tumour  from  the  cavity  of  the  uterns 
into  the  vagina,  and  even  through  the  os  externum.1 — When  this 
takes  place,  it  is  generally  mistaken  for  the  uterus  itself,  and 
has  been  called  by  many  a  descent  of  this  organ.  The  following 
case  will  show  the  nature  of  this  disease. 

Mrs.  B.  had  suffered  from  time  to  time  nearly  eighteen  months 
with  a  profuse  discharge  of  blood  from  the  vagina,  for  which 
much  had  been  done,  but  to  no  useful  purpose.  She  was  about 
twenty-three  years  of  age,  had  had  two  children,  and  was,  pre- 
viously to  these  discharges,  of  a  good  constitution.  She  came  to 
this  city  to  place  herself  under  my  care — at  this  time,  she  was 
very  feeble,  and  almost  bloodless,  as  she  had  suffered  a  most  pro- 
fuse hemorrhage  a  few  days  before.  By  an  examination  per 
vaginam,  I  discovered  a  polypus  about  the  size  of  a  walnut,  the 
pedicle  of  which  was  within  the  uterus.  I  begged  the  assistance 
of  my  friend  Dr.  Homer.  We  applied  a  ligature  without  diffi- 
culty close  to  the  os  tincae  around  the  neck  of  the  tumour — it 
separated  in  about  four  days  without  any  unpleasant  symptoms, 
though  the  patient  laboured  under  the  fever  from  excessive  hemor- 
rhage, for  nearly  two  weeks.  This,  however,  yielded  gradually ; 
and  she  returned  home  free  from  disease,  and  continued  to  im- 
prove up  to  the  last  account  we  received  of  her.2 

It  is  this  condition  of  the  polypus,  which  has  given  rise  to  the 
absurd  stories  related  by  many  of  the  older  authors,  especially 
Cesalpinus,  JEtius,  Paul  Eginetta,  Carpi,  &c. ;  of  the  uterus 
having  been  amputated,  and  the  woman  conceiving  afterwards. 
Levret,  sur  Polypus  Uterine,  p.  29. 

The  mechanism  of  the  expulsion  of  the  polypus  is  very  simi- 
lar to  that  of  an  abortion  ;J  that  is,  the  os  uteri  is  gradually,  but 

1  See  Dr.  Denman's  cases  at  the  end  of  this  chapter ;  and  the  case  just  related, 
page  261. 

*  Since  writing  the  above,  I  have  met  with  several  cases  of  polypi,  all  treated 
with  the  happiest  effects  by  ligature. 

1  The  explanation  of  Levret,  of  the  mechanism  which  nature  employs  when 
she  attempts  the  expulsion  of  this  species  of  polypus,  is  so  ingenious,  and  so  con- 
formable to  the  general  laws  which  govern  the  uterus,  that  we  cannot  resist  the 
temptation  to  transcribe  it  at  length. 

"  Le  polype  uterin  de  la  premiere  espece  ayant  une  fois  pris  naissance  au  fond 
de  la  matrice  par  quelque  cause  que  ce  puisse  etre,  croit  peu  &  peu  sans  que  la 
femme  ni  le  chirurgien  meme  s'en  appercoivent;  en  effet,  lorsque  la  malade  se 
plaint  pour  la  premiere  fois  on  ne  peut  d'abord  decider  si  la  cause  de  son  mal  est 
un  polype  on  toute  autre  maladie:  car  il  n'y  a  dans  les  premiers  terns  aucun  signe 
characteristique  de  eon  existence. 

"  Ce  corps  etranger  ayant  acquis  avec  le  terns  plus  de  volume,  oblige  la  matrice 


2-U  POLYPUS    OF    THE    UTERUS. 

successfully  opened  so  far  as  to  permit  the  extrusion  of  this  sub- 
stance. When  this  takes  place,  the  body  of  the  polypus  is  with- 
out the  os  uteri,  while  its  pedicle  maintains  its  attachment  to  the 
inner  surface  of  the  uterus  itself.  If  it  be  examined  now,  it  will 
appear  to  occupy  the  vagina,  and  might  be  supposed  to  proceed 
from  its  surface  ;  yet,  by  a  careful  search,  its  pedicle  will  be  found 
to  be  within  the  uterus,  and  the  os  uteri  surrounding  it  entirety, 
as  a  sphincter ;  and  as  such  it  acts,  agreeably  to  Levret.  The 
polypus  has  been  suddenly  discharged  from  the  cavity  of  the 
uterus,  by  falls  or  other  violence. 

He  says,  that  in  this  species,  "  hemorrhage  is  necessarily  a  con- 
sequence; but  that  it  never  appears,  until  the  body  of  the  tumour 
has  in  a  great  measure  freed  itself  from  the  orifice  of  the  uterus, 
and  until  it  begins  to  extend  itself  into  the  vagina;  then  the 
sphincter  of  the  uterus,  (that  is,  the  os  uteri,)  compresses  the  ex- 
ternal veins  of  the  polypus ;  in  consequence  of  which,  these  veins 
become  varicose,  and  finally  burst;  and  their  rupture  gives  rise 
to  a  hemorrhage,  which  is  renewed  at  irregular  periods,"  p.  25. 

It  does  not  appear  to  disturb  the  economy  of  gestation,  or  in- 
terfere with  the  process  of  labour  in  some  cases;  Dr.  Churchill 
gives  an  interesting  account  of  a  labour  that  was  successfully 
terminated,  but  which  had  a  fatal  termination,  owing  to  a  poly- 
pus in  the  uterus;  we  will  relate  it  in  his  own  words.  "The 
patient  after  a  natural  labour,  appeared  for  awhile  to  be  going 
on  well.  In  a  short  time,  however,  a  flooding  came  on,  resisting 
all  the  usual  means  for  arresting  uterine  hemorrhage,  and  in 
eight  or  ten  hours  the  patient  died.  Upon  examining  the  uterus 
after  death,  there  was  a  large  cellular  polypus,  descending  from 
the  fundus,  and  which  it  was  evident  had  prevented  the  due  con- 
traction of  the  uterus.  No  vessel  could  be  detected  in  the  poly- 
pus."— Churchill  on  the  Principal  Diseases  of  Females,  p.  191. 

a  se  dilater,  quoique,  par  degres  tres  insensibles ;  mais  comme  1'attache  de  cette 
tumeur  occupe, dans  tous  Jes  terns,  au  fond  de  la  matrice,  bien  moins  d'espaceque 
le  placenta  d'un  enfant,  en  quelqu'  etat  d'accroissement  que  soit  ce  dernier,  toutes 
choses  neanmoins  etant  d'ailleurscgales,  il  faut.non  pas  que  le  fait  dilater  1'arriere- 
faix  dans  la  grosessa;  mais  que  lesparois  de  ce  viscerese  pretent  unpeu,  de  meme 
de  son  fond,  a  cette  puissance  dilatante  etrangere.  Or  il  n'est  point  en  ces  cas  des 
loix  naturelles  a  sa  destination  qui  sollicitent  les  parois  de  cette  organe;  elles 
doivent  done  rdsister:  le  polype  doit  etre  comprime;  il  doit  done  aussi  s'allonger, 
plus  ou  moins,  a  raison  de  son  plus  on  moins  solidite.  Alors  il  s'insinue  dans  le 
col  de  cet  organe,  parce  qu'il  y  trouve  moins  de  resistance.  Parvenu  au  sphyncter 
de  1'orifice,  il  le  force  peu  a  peu,  et  s'introduit  dans  le  vuide  qu'il  s'y  pratique, 
comme  le  feroit  un  coin:  enfin  1'extremite  du  polype  ne  trouvant  plus  rien  qui  le 
gene  s'etend  en  avant  et  au  large  dans  le  vagin,  et  la  tumeur  prend  plus  ou  moins 
de  volume,  selon  que  le  permettent  mille  diverses  circonstances,  qui  sont  plus 
aisees  a  concevoir  qu'  a  detailler. 

"  Le  pedicule  ne  pent  pas  s'etendre  au  large  comme  le  reste  de  la  tumeur,  1'ori- 
fice de  la  uterus  qui  souffre  un«spcce  de  violence,  le  comprime ;  le  polype  est  done 
comme  ctrangle  en  cet  endroit:  il  faut  qu'il  prenne  la  figure  pyrilbrme;  de  la 
naissent  les  varices;  c'est  la  vraie  cause  de  1'hemorrhagie,  p.  38."  ~ 

' 


POLYPUS  OF   THE   UTERUS. 

These  frequent  bleedings,  if  not  relieved  by  the  removal  of  the 
tumour,  eventually  exhaust  the  woman ;  but  rather  by  their  per- 
tinacity, than  by  their  immediate  excess;  yet  examples  are  upon 
record,  where  a  sudden  hemorrhage  has  destroyed  the  woman  im- 
mediately. Levret,  p.  30. 

These  polypi  seem  not  in  general  to  do  injury  to  the  proper 
substance  of  the  uterus;  for  several  relate,  that  this  organ  was 
found  sound  after  deaths  occasioned  by  the  wasting  hemorrhages 
from  the  surface  of  the  tumours.  Levret,  p.  42. 

Agreeably  to  Levret,  the  signs  of  this  species  of  polypus  are, 
"  Whenever  we  examine  a  woman  who  has  been  labouring  under 
a  discharge  of  blood  from  the  vagina,  or  of  a  falling  of  the  womb, 
whether  they  are  both  found  together,  or  separately,  if  we  find  in 
the  vagina  a  pyriform  body,  the  insulated  top  of  which  passes 
through  the  orifice  of  the  uterus,  without  destroying  its  circular 
form,  we  may  always  with  certainty  be  assured,  if  we  except 
pregnancy,  that  it  is  a  polypus  attached  by  its  pedicle  to  the 
uterus,  and  that  it  is  in  the  most  favourable  condition  for  the  liga- 
ture," p.  48.  See  figure  1,  Plate  IV. 

In  the  second  species,  the  finger  cannot  pass  entirely  around 
the  pedicle,  as  in  the  first;  and  the  point  which  opposes  the  finger 
making  its  circle  is  a  little  above  the  orifice  of  the  uterus,  and  is 
found  to  be  the  pedicle  of  the  polypus,  inserted  on  the  outside  of 
the  neck  of  the  uterus.  The  os  uteri  may  also  be  felt.  See  fig. 
•2.  Plate  IV. 

This  species  is  not  commonly  accompanied  by  hemorrhage, 
because  the  pedicle  does  not  become  strangulated,  as  in  the  first; 
but  there  is  an  increase  of  vaginal  secretion.  This  species,  never- 
theless, is  a  genuine  polypus. 

The  third  species  is  thus  distinguished:  when  there  is  in  the 
vagina  a  moveable  tumour,  with  a  narrow  nock  attached  to  the 
orifice  of  the  uterus,  but  in  such  a  manner  as  to  leave  the  orifice 
free,  we  may  be  pretty  certain  that  it  is  a  polypus  of  this  kind. 
In  this  case,  the  mouth  of  the  uterus  will  be  obliquely  situated,  as 
regards  the  axis  of  the  vagina,  in  consequence  of  that  part  of  the 
neck  of  the  uterus  to  which  the  tumour  is  attached  descending  a 
little  lower  than  the  other  portions  of  it,  from  the  weight  of  the 
tumour.  This  species  is  not  necessarily  attended  by  hemorrhage. 

All  these  species  have  but  one  common  remedy;  namely,  ex- 
tirpation by  ligature.  In  the  first,  it  will  be  seen,  that  this  remedy 
cannot  be  applied,  until  the  tumour  has  descended  into  the  vagina, 
and  consequently  will  not  admit  of  a  cure,  until  that  event  takes 
place.  It  would  then  seem  desirable  that  this  escape  of  the 
tumour  from  its  confinement  should  be  promoted,  if  possible,  so 
soon  as  it  shall  be  determined  that  there  exists  a  polypus  within 
the  uterus.  But  how  shall  it  be  ascertained,  that  there  is  a  tumour 
in  the  cavity  of  the  uterus,  since  no  particular  symptoms  mark 


266  POLYPUS    OF    THE    UTERUS. 

this  condition  until  it  falls  into  the  vagina  ?  There  may  be  a  great 
difficulty  in  distinguishing  this  condition  at  such  a  period ;  but 
we  are  informed,  before  this  takes  place,  the  woman  suffers  pain 
resembling  labour ;  and  when  pregnancy  cannot  account  for  these 
pains,  nor  dysmenorrhcea,  it  might  be  well  to  examine  the  patient 
per  vaginam.  In  such  an  examination,  the  tumour  might  be  felt, 
making  its  way  through  the  os  uteri:  if  so,  it  would  be  every 
way  desirable  to  facilitate  its  progress ;  and  for  this  purpose  I1 
would  ask,  what  would  be  the  probable  effect  of  the  secale  cor- 
nutum  ? 

The  uterus  will  also  be  found  enlarged,  and  may  be  felt  above 
the  mons  veneris;  at  least  this  will  be  the  case  for  a  certain  pe- 
riod ;  or  until  the  tumour  shall  pass,  either  in  part  or  altogether, 
through  the  os  uteri. 

Nothing  illustrates  the  routine  of  practice  so  well  as  the  recital 
of  cases ;  and  no  cases  can  be  more  interesting  and  satisfactory 
than  those  related  by  Dr.  Denman.  We  shall,  therefore,  tran- 
scribe them  for  the  benefit  of  those  who  may  not  have  the  advan- 
tage of  possessing  his  work ;  as  well  as  conveying  to  such,  in  per- 
spicuous language,  the  histories  of  several  highly  useful  cases, 
treated  with  all  the  ability  that  that  great  metropolis,  London, 
could  furnish. 

Case  First. 

"A  single  lady,  twenty-two  years  of  age,  had,  for  a  considera- 
ble time,  been  subject  to  frequent  and  profuse  returns  of  uterine 
hemorrhage,  which  resisted  all  the  means  that  could  be  devised 
for  her  relief,  and  at  length  reduced  her  to  a  state  of  great  weak- 
ness. Dr.  Turton,  (whose  worth  and  continued  friendship  to  me, 
I  am  happy  on  every  occasion  to  acknowledge,)  was  the  physician 
who  attended;  and  he,  suspecting  some  local  disease,  desired  I 
might  be  permitted  to  make  inquiry.  I  discovered  a  polypus,  not 
of  a  large  size,  lying  low  in  the  vagina.  When  I  came  to  pass 
the  ligature,  there  was  much  embarrassment  from  the  state  of  the 
parts,  any  injury  to  which  I  was  solicitous  to  avoid.  On  the  fifth 
day  from  the  time  of  my  passing  it,  it  came  away;  but  the  poly- 
pus could  not  be  extracted  without  much  caution  and  trouble. 
There  was  no  return  of  the  hemorrhage;  she  soon  recovered  her 
strength,  and  in  a  few  months  was  married.  She  has  since  had 
seven  fine  children,  with  safe  and  easy  labours.  This  polypus 
weighed  four  ounces." 

Case  Second. 

"Another  young  lady  had  long  suffered  from  frequent  uterine 
hemorrhages,  together  with  most  violent  pains  recurring  in  the 


V 


POLYPUS   OF   THE   UTERUS.  267 

manner  of  those  of  labour.  High  up  in  the  vagina,  just  cleared 
through  the  os  uteri,  I  discovered  a  small  polypus,  round  which 
a  ligature  was  with  difficulty  passed.  The  late  Mr.  Hunter  was 
with  me  at  the  time.  When  I  began  to  tighten  the  ligature,  she 
complained  of  very  severe  pain,  and  presently  vomited.  The 
ligature  was  immediately  slackened,  but  on  every  future  attempt 
to  draw  it  tighter,  the  symptoms  were  instantly  produced.  After 
many  trials,  I  was  obliged  to  desist  altogether,  leaving  the  liga- 
ture loose  round  the  polypus;  merely  to  keep  up,  in  the  mind  of 
the  patient,  some  faint  hope  of  benefit.  The  health  of  this  patient 
was  very  bad  when  I  first  saw  her,  and  in  about  six  weeks  from 
the  time  of  the  operation  she  died. 

"Leave  being  given  to  open  the  body,  the  uterus  was  found 
inverted,  and  the  ligature  to  have  passed  over  the  inverted  part, 
which  occasioned  all  the  symptoms  before  mentioned.  This 
polypus  could  not  have  weighed  more  than  one  ounce,  and  had 
a  very  short,  if  it  could  be  said  to  have  a  stem ;  so  that  the  ute- 
rus could  not  in  this  case  have  been  inverted  mechanically,  but 
by  its  own  vehement  action,  excited  to  expel  the  polypus,  which, 
like  any  other  extraneous  and  offending  body,  was  a  perpetual 
cause  of  irritation." 

Case  Third. 

"Many  years  ago,  I  visited  a  lady,  who  had  for  a  long  time 
suffered  greatly  from  various  uterine  complaints,  and  was  sup- 
posed to  have  a  cancer  in  the  uterus,  of  which  a  general  aspect 
gave  very  strong  indications,  but  on  examination  I  found  a  large 
polypus  in  the  vagina.  The  late  Dr.  Ford,  than  whom  no  one 
was  more  intelligent  or  expert  in  practice,  was  in  consultation 
with  me.  I  passed  the  ligature  and  drew  it  tight,  confidently 
expecting  a  happy  termination  of  the  case.  The  stem  of  the 
polypus  was  very  thick,  and  it  required  eight  or  nine  days'  action 
of  the  ligature  to  divide  it.  'When  I  had  removed  the  polypus, 
I  was  very  much  mortified  to  find  a  new  substance,  nearly  the 
size  of  that  which  had  been  taken  away,  in  the  vagina.  Her 
health  being  very  infirm,  it  was  thought  advisable  for  her  to  go 
a  short  distance  in  the  country,  for  the  chance  of  establishing 
her  health,  before  another  operation.  But  a  colliquative  diarrhoea 
•with  aphthae,  came  on ;  she  gradually  declined,  and  about  the  end 
of  the  month  she  died. 

"  Of  this  repullulation,  if  it  were  such,  I  have  never  seen  any 
other  instance,  so  early  after  the  operation ;  and  it  might  be  attri- 
buted, 1st,  to  the  thickness  of  the  stem ;  or,  2d,  to  the  slow  decay 
of  the  stem;  or,  3d,  to  a  cancerous  disposition  of  the  uterus;  or, 
4th,  to  a  large  portion  of  the  polypus  remaining  in  the  uterus; 
besides  what  was  discoverable  in  the  vagina.  If  a  case  similar 


268  POLYPUS    OF   THE    UTERUS. 

to  this  were  again  to  occur  to  me,  I  should  certainly  act  'more 
speedily  with  the  ligature,  and  however  reduced  the  patient  might 
be,  should  feel  justified  in  passing  the  ligature  on  the  second  ex- 
crescence, as  affording  the  only  chance  of  saving  the  patient  ;  but 
this  is,  perhaps,  to  be  considered  as  an  instance  of  the  great  mis- 
chief done  to  the  constitution,  by  too  long  delaying  the  opera- 
tion." 


Case  Fourth. 
?*«>i;«<(  *»i»7  lv  ii.'f,«-y.-l  -itfr    ji)*irviTp  *<->v>t{  tffiv^tittrt  .i«->r?«\|  *?.4j 

"  A  lady,  about  sixty  years  of  age,  who  had  several  children, 
had,  with  violent  pain,  frequent  hemorrhages  from  the  uterus,  so 
profuse  as  to  bring  her  at  each  time  of  their  return  into  thue 
greatest  danger.  When  she  permitted  me  to  make  an  examina- 
tion, there  was  no  polypus  in  the  vagina,  but  the  uterus  was  much 
distended,  and  the  os  uteri  being  opened  nearly  to  one  third  of  its 
circumference,  I  could  discover  within,  and  pressing  upon  it,  a 
tumour  of  apparently  a  very  large  size.  In  the  course  of  a  few 
weeks,  an  immensely  large  polypus  dropped  into  the  vagina.1 
Her  health  was  much  reduced,  and  the  extirpation  of  the  polypus 
appearing  the  only  chance  of  saving  her,  I  made  many  and  stre- 
nuous attempts  to  pass  the  ligature,  but  without  success.  I  then 
procured  a  large  and  different  instrument,  like  that  used  in  tying 
the  tonsils,  but  with  this  I  was  also  foiled.  In  my  endeavours  to 
pass  this  instrument  round  the  polypus,  the  surface  was  abraded, 
a  blood  vessel  of  a  considerable  size  was  wounded,  and  there  was 
a  loss  of  blood  which  rendered  the  patient  still  more  weak.  After 
a  few  days  without  any  instrument,  I  gradually  introduced  my 
hand  into  the  vagina,  got  the  ligature  over  the  polypus,  and  then 
tightened  it.  Dr.  Orme  and  Mr.  Croft  were  with  me  at  the  time. 
But  many  complaints  came  on,  and  she  died  in  a  few  days,  be- 
fore the  polypus  could  be  extirpated. 

<;  The  blood  vessels  which  convey  nourishment  to  a  polypus 
probably  bear  a  relation  to  its  size,  and  must,  of  course,  be  some- 
times very  large,  so  that  in  passing  the  ligature,  it  behooves  us  to 
be  very  careful  that  we  do  not  wound  the  polypus  ;  and,  perhaps, 
in  every  case  when  the  polypus  is  large,  it  would  be  better,  if 
possible,  to  introduce  the  hand,  for  the  conveyance  of  the  ligature, 
than  to  use  the  instrument.  Much  will  also  depend  on  the  tex- 
ture of  the  polypus,  which  is  sometimes  so  slight  as  to  resemble 
an  injected  and  corroded  liver  or  kidney.  I  remember  a  case  in 
which,  though  I  only  took  a  common  examination,  and  the  usual 
caution,  so  violent  a  hemorrhage  was  occasioned,  that  I  thought 
the  patient  would  have  died  instantly.  Were  a  case  similar  to 

*'In  this  case  the  secale  cornutam  would  most  probably  have  succeeded  in  ex- 
pelling the  tumour,  and  should  always  be  tried  in  such  cases. 


POLYPUS    OF    THE    UTERUS.  269 

this  to  occur  to  me  again,  I  should  be  disposed  to  try  the  effect 
of  styptic  injections,  deferring  any  attempt  to  pass  the  ligature, 
till  I  had  seen  the  effect  which  would  be  produced  by  them. 

"  The  three  preceding  cases  are  the  only  ones,  among  a  very 
great  number,  in  which  I  have  not  been  successful  ;  and  I  have 
judged  it  right  to  state  them  thus  circumstantially  to  set  others 
upon  their  guard,  and  to  prepare  them  for  the  possibility  of  dis- 
appointment. 

"  In  the  museum  of  the  late  Dr.  Hunter,  there  is  a  large  poly- 
pus from  which  an  engraving  was  made,  and  by  the  register  it 
appears,  that  after  many  attempts  to  pass  the  ligature,  without 
success,  this  patient  died.  Perhaps  by  a  knowledge  of  the  causes 
of  the  miscarriages  of  others,  (as  in  case  4th,  just  recited,)  sub- 
sequent trials,  even  in  the  polypi  which  are  of  the  largest  size, 
may  be  more  fortunate.  I  have  very  great  pleasure  in  relating 
the  following  case  which  was  lately  under  my  care." 


-'•'.     ••  .•--    •  •••          -•       *  - 

Case  Fifth. 

"  A  foreign  lady,  who  was  born  and  had  lived  the  greatest 
part  of  her  time  in  a  hot  climate,  applied  to  me.  She  had  had 
every  day,  for  more  than  three  years,  a  very  considerable  dis- 
charge of  blood  from  the  uterus,  together  with  others  of  a  diffe- 
rent kind  and  complexion,  by  which  her  strength  was  very  much 
reduced.  She  had  been  attended  by  different  gentlemen,  who 
had  not  given  any  decided  opinion  of  the  nature  of  her  disease. 
When  I  first  examined  her,  I  was  indeed  very  much  surprised; 
for  not  only  the  whole  vagina  was  filled  up  with  a  fleshy  sub- 
stance, but  the  os  uteri  was  as  completely  dilated  as  when  the 
head  of  a  child  is  passing  through  it,  and  the  cavity  of  the  uterus 
appeared  to  be  much  distended  and  filled  with  the  same  substance. 
I  at  first  hesitated  whether  I  should  make  an  attempt  to  pass  the 
ligature,  as  I  could  not  reach  the  stem  of  the  substance,  but  after 
deliberating  on  the  state  of  the  patient,  who  must  soon  perish, 
unless  relief  could  be  given,  and  knowing  that  if  the  ligature  could 
be  passed,  I  should  have  the  power  either  of  proceeding,  or  of 
stopping  on  the  appearance  of  any  untoward  symptom,  I  deter- 
mined to  make  a  trial.  The  first  and  second  attempts  to  pass 
the  ligature  were  fruitless,  but  I  at  length  conveyed  the  ligature 
beyond  the  bulk  of  the  tumour,  and  far  beyond  my  reach,  by 
means  of  a  piece  of  thin  cane  notched  at  the  end.  The  ligature 
being  daily  drawn  gradually  tighter,  was  at  liberty  on  the  sixth 
day.  The  external  parts  were  unusually  contracted,  and  as  any 
endeavours  to  bring  away  the  polypus  at  that  time  must  have 
failed,  it  was  left  in  the  vagina  to  soften  and  decay.  On  the  ninth 
day  after  the  ligature  was  come  away,  she  had  pains  as  regular 


270  POLYPUS    OF    THE     UTERUS. 

as  those  of  labour ;  and  when  the  os  externum  became  somewhat 
dilated,  I  laid  hold  of  a  portion  of  the  tumour,  first  with  my  fin- 
gers and  then  with  a  small  sharp-pointed  hook,  favouring  the 
expulsion  of  it  as  well  as  I  could  during  the  pains,  by  which  it 
was  at  length  propelled  with  considerable  force,  after  a  labour  of 
four  hours'  continuance.  From  that  time  to  the  end  of  five 
weeks,  there  was  not  any  discharge  of  any  consequence.  Then 
she  menstruated  regularly,  and  returned  home  in  perfect  health. 

"This  polypus,  which  was  the  largest  I  ever  saw,  was  put  into 
the  hands  of  Dr.  Baillie,  who  saw  the  patient  during  the  opera- 
tion. It  weighed  two  pounds  and  three  ounces ;  so  that,  allow- 
ing for  its  decay,  perhaps  it  could  not  originally  have  weighed 
less  than  three  pounds.  But  the  violence  of  the  symptoms  does 
not  always  depend  on  the  large  or  small  size  of  the  polypus. 

"  When  polypi  are  too  large  to  be  extracted  without  much  dif- 
ficulty after  their  separation,  no  harm  can  arise  from  their  re- 
maining some  days  in  the  vagina,  as  I  have  found  in  several 
instances ;  and  their  bulk  hourly  lessening  by  decay,  their  ex- 
traction is  rendered  more  easy. 

"  These  cases  lead  to  an  observation  on  the  difference  between 
what  is  properly  meant  by  the  terms  polypus,  and  excrescence. 
By  the  former  is  to  be  understood  those  excrescences  that  arise 
distinctly  from  the  uterus  or  vagina;  and  by  the  latter,  a  morbid 
enlargement  of  those  parts.  The  first  of  these  generally  admits 
of  extirpation  with  safety  and  advantage ;  but  the  latter,  though 
they  admit  of  extirpation,  and  even  promise  success,  cannot  with 
propriety  and  safety  be  removed." 


Case  Sixth. 

"  We  were  called  to  Mrs.  A.  in  January,  1833,  who  was  losing 
much  blood  every  few  days  from  the  uterus.  Upon  examination 
per  vaginam,  the  mouth  of  the  uterus  was  more  open  than  natural, 
admitting  the  point  of  the  finger  to  pass  a  little  distance  within  it 
without  difficulty:  the  whole  neck  was  larger  than  usual,  but 
nearly  of  the  ordinary  length.  Rest,  and  restricted  antiphlogistic 
diet  was  ordered,  with  injections,  per  vaginam,  of  pretty  strong 
lead  water;  that  is,  two  drachms  of  the  acetate,  to  fibiss.  of  water, 
three  or  four  times  a  day.  These  would  seem  to  control  the 
hemorrhage  temporarily,  but  they  would  recur,  at  short  intervals, 
and  by  very  slight  exertions.  The  cicuta,  in  increasing  doses, 
together  with  liberal  doses  of  the  extract  of  rhatany,  were  steadily 
persevered  in,  with  some  degree  of  advantage  as  regarded  the 
quantity  of  discharge.  This  plan  was  persevered  in  until  August ; 
at  this  time,  an  alarming  discharge  took  place,  so  as  almost  to 
exhaust  my  patient.  On  an  examination  now,  the  neck  of  the 


MODE  OF  OPERATING  FOR  POLYPI. 

uterus  was  found  much  enlarged,  and  it  immediately  occurred  to 
me,  that  this  enlargement  was  owing  to  a  concealed  polypus 
making  its  way  through  it :  with  a  hope  of  ending  this  work,  I 
ordered  thirty  drops  of  the  vinous  tincture  of  the  secale  cornutum 
every  four  hours.  In  the  course  of  48  hours,  slight  uterine  pains 
were  produced,  which  were  permitted  to  continue  for  two  days, 
and  were  then  checked  by  morphia ;  at  the  end  of  a  week,  they 
were  again  renewed,  and  so  on  at  intervals,  for  two  months. 
On  touching  the  mouth  of  the  uterus  now,  a  smooth  round  body, 
of  the  size  of  a  large  cherry,  was  perceived  at  its  extremity, 
which,  to  my  great  satisfaction,  confirmed  the  opinion  I  had  given: 
the  hemorrhage  was  now  very  much  diminished,  and  could 
always  be  stopped  by  a  small  tampon  of  sponge.  In  this  man- 
ner things  went  on  for  several  months,  the  substance  gradually 
protruding  itself,  by  the  occasional  use  of  the  tincture  of  ergot, 
and  eventually,  by  December,  1834,  the  uterus  freed  itself  of  a 
polypus  as  large,  nearly,  as  a  goose-egg,  forming  a  neck  or  pedi- 
cle of  considerable  thickness,  more  than  an  inch  in  diameter.  I 
applied  the  wire  ligature,  and  the  tumour  fell  off  on  the  eleventh 
day;  no  unpleasant  symptom  attended  its  application  or  followed 
its  separation :  my  patient  is  rapidly  recovering  from  the  im- 
mense loss  of  blood,  during  #period  of  more  than  two  years'  con- 
tinuance. 

"The  late  Dr.  Hamilton,  of  Glasgow,  obliged  me  with  the 
drawing  of  a  polypus  which  weighed  one  pound  and  four  ounces, 
and  had  dropped  through  the  os  externum,  inverting  and  drag- 
ging along  with  it  the  fundus  of  the  uterus.  The  patient  died. 
Had  the  nature  of  this  complaint  been  understood  in  due  time, 
it  would,  in  all  likelihood,  have  been  possible  to  have  tied  and 
extirpated  it,  before  it  had  occasioned  so  much  mischief.  It  is 
an  example,  among  many  others,  of  the  impropriety  of  waiting 
till  the  polypus  is  excluded  through  the  os  externum,  before  we 
attempt  to  tie  it;  an  opinion  which  some  have  entertained." 


SECT.  IV. — Mode  of  Applying  the  Ligature  for  Polypi. 

We  shall  give  Mr.  Clarke's  mode  of  applying  the  ligature,  with 
our  own  experience  upon  this  plan. 

He  directs,  that  previously  to  performing  the  operation,  the 
rectum  of  the  patient  should  be  emptied  by  a  clyster,  or  the  in- 
testinal canal  may  be  cleared  in  its  whole  extent  by  a  mild  pur- 
gative. For  a  short  time  before  the  commencement  of  the  ope- 
ration the  patient  should  be  kept  in  the  upright  posture,  that  the 
neck  of  the  tumour  may  be  more  within  reach. 

"As  the  tumour  possesses  different  degrees  of  convexity  in  dif- 
ferent cases,  and  as  the  distance  of  its  neck  from  the  os  externum 


272  MODE   OF   OPERATING   FOR   POLYPI. 

is  very  various,  the  practitioner  must  be  provided  with  two  or 
three  rods  of  different  lengths,  made  of  flexible  metal,  so  as  to  be 
capable  of  being  adapted  to  the  shape  of  the  tumour.  The 
author's  brother,  the  late  Dr.  Clarke,  has  contrived  a  brass  rod, 
which,  being  received  into  a  hollow  handle,  is  capable  of  having 
its  length  altered  as  each  case  may  require ;  and  by  this  means 
the  multiplication  of  instruments  is  rendered  unnecessary. 

"A  silver  cannula,  of  a  length  sufficient  to  reach  from  the  neck 
of  the  tumour  to  the  distance  of  an  inch,  or  an  inch  and  a  half 
from  the  os  externum,  should  be  prepared ;  and  near  the  extre- 
mity which  is  to  hang  out  of  the  external  parts,  there  should  be 
placed  two  small  shoulders,  round  which  the  ends  of  the  ligature 
may  be  twisted.  A  sort  of  windlass  has  been  recommended  for 
this  purpose  in  the  cannula;  but  this  is  quite  unnecessary,  and 
renders  the  instrument  more  complicated. 

"The  ligature  should  be  made  of  waxed  silk,  of  such  a  thick- 
ness, as  neither  to  cut  the  neck  of  the  tumour,  nor  to  break,  nor 
block  up  the  cannula.1  In  order  to  pass  the  ligature  through  the 
cannula,  a  long  piece  of  thin  brass  wire  should  be  ready.  This 
is  absolutely  necessary;  because,  when  the  ligature  becomes 
slippery  and  pliable,  it  will  not  be  possible  to  push  it  through  the 
cannula.  The  patient  should  be  placed  upon  a  bed.  She  should 
lie  upon  her  left  side,  and  her  knees  should  be  drawn  up  towards 
the  abdomen.  If  the  external  parts  should  not  be  readily  dila- 
table, they  should  be  dilated.  The  forefinger  of  the  practitioner's 
left  hand,  (previously  oiled,)  is  now  to  be  carried  through  the 
vagina  to  the  neck  of  the  tumour.  The  brass  rod  (previously 
prepared  with  the  ligature,  and  its  curvature  adapted  to  the  shape 
of  the  tumour,)  is  to  be  passed  up  by  the  right  hand  to  that  part 
of  the  neck  of  the  tumour  where  the  forefinger  of  the  other  hand 
is  placed.  The  ligature  is  then  to  be  secured  by  the  finger,  and 
the  brass  rod  is  to  be  carefully  carried  round  the  neck  of  the 
tumour,  till  it  comes'to  that  part  where  the  ligature  was  secured. 
The  practitioner  is  now  to  secure  also  under  his  finger  that  part 
of  the  ligature  which  has  been  carried  round  the  neck  of  the 

1  We  are  convinced,  from  late  experience,  that  a  double  silver  cannula,  rather 
longer  than  it  is  ordinarily  made,  armed  with  a  piece  of  fine  steel  well  annealed 
wire,  is  much  the  simplest  and  best  instrument.  We  have  tried  the  rods,  but  did 
not  succeed  in  applying  the  ligature.  We  merely  mention  the  fact,  without  under- 
valuing Mr.  Clarke's  instrument.  The  failure  may  have  been  owing  to  our  own 
mal-adroitness  rather  than  to  the  want  of  suitableness  in  the  instrument  itself. 
We,  however,  succeed  without  difficulty  with  the  long  silver  double  cannula.  We 
think  the  following  advantages  attach  to  the  cannula  and  wire.  First,  its  whole 
powers  are  more  at  the  command  of  the  operator.  Secondly,  the  loop  can  always 
be  enlarged  or  diminished  at  pleasure.  Thirdly,  it  can  be  more  easily  removed, 
or  have  its  location  changed,  if  this  be  necessary.  Fourthly,  any  degree  of  pres- 
sure can  be  made, , by  a  pair  of  pliers,  that  may  be  deemed  expedient.  Fifthly. 
the  tumour  is  more  completely  strangled,  and  consequently,  will  be  soon  detached 
by  ulceration.  Sixthly,  it  requires  but  one  instrument. 


V 


MODE    OF    OPERATING    FOR    POLYPI. 

tumour,  and  the  rod  is  to  be  carefully  withdrawn.  In  some  cases, 
it  will  be  found  more  convenient  to  steady  a  part  of  the  ligature 
with  the  rod,  and  to  carry  the  other  part  of  the  ligature  round  the 
neck  of  the  tumour  with  the  finger.  In  doing  this  part  of  the 
operation,  great  care  is  to  be  taken  not  to  include  any  part  of 
the  os  uteri.  Before  the  ligature  is  tightened,  the  patient  is  to 
be  desired  to  inform  the  operator  if  she  feels  pain ;  because,  if 
the  tumour  only  is  included  in  the  ligature  no  pain  will  be  felt. 
"  The  two  extremities  of  the  ligature  which  hang  out  of  the  os 
externum  are  now  to  be  drawn  through  the  cannula,  by  the  piece 
of  wire,  (which  had  been  previously  doubled,  and  carried  through 
the  cannula,  so  as  to  form  a  noose  projecting  from  it,)  and  after 
the  cannula  has  been  gently  passed  up  to  the  neck  of  the  tumour, 
they  are  to  be  drawn  tight,  and  are  then  to  be  twisted  round  the 
shoulders  of  the  cannula,  where  they  are  to  be  made  secure. 
The  ligature,  therefore,  should  be  long  enough  to  encircle  the 
neck  of  the  tumour,  to  be  carried  through  the  cannula,  and  a  suf- 
ficient length  of  it  should  remain  to  be  affixed  to  the  shoulders  of 
it.  More  than  one  ligature  should  always  be  prepared,  lest  that 
which  is  first  used  should  become  too  slippery  to  be  managed. 

"After  threading  the  eye  of  the  rod,  one  extremity  of  the  liga- 
ture is  to  be  twisted  once  or  twice  round  the  instrument,  whilst 
the  other  hangs  loose.  The  patient  should  be  made  acquainted 
with  the  shape  and  situation  of  the  instrument,  that  it  may  not 
be  liable  to  be  removed  when  she  gets  up  to  make  water.  She 
is  also  to  be  desired  to  remain  constantly  upon  her  side,  and 
should  not  be  allowed  to  move  from  one  side  to  the  other,  unless 
when  the  practitioner  is  present.  For  want  of  attention  to  this 
caution,  there  is  reason  to  believe  that  the  cannula  has  been  in- 
advertently pressed  against,  and  its  extremity  pushed  through, 
the  uterus  of  the  patient,  so  as  to  occasion  her  death.  In  the 
engraving  given  of  the  polypus  cannula,  there  may  be  seen  a 
contrivance,  by  means  of  which  this  accident  may  be  prevented. 
The  cannula  is  made  of  the  same  diameter  from  one  end  to  the 
other,  and  a  spiral  screw  is  cut  upon  it.  To  this  spiral  screw  is 
adapted  another  screw,  placed  in  the  centre  of  a  kind  of  shield, 
which,  (when  the  ligatures  are  fastened,)  is  to  be  placed  in  con- 
tact with  the  external  parts.  The  shield  in  the  plate  is  of  a  cir- 
cular form ;  but  in  women  who  are  corpulent,  it  may  be  more 
convenient  that  its  shape  should  be  oval. 

"  The  patient  is  now  to  be  left,  and  great  care  is  to  be  taken 
by  the  nurse  that  the  cannula  is  not  moved  when  the  contents  of 
the  bladder  are  expelled. 

"Every  day  the  practitioner  is  to  examine  the  state  of  the 
ligature;  and  as  often  as  it  is  found  at  all  too  slack,  it  is  to  be 
tightened.     The  mode  of  tightening  it  requires  particular  atten- 
tion.    If  the  cannula  should  happen  to  be  long,  the  practitioner 
18 


274  MODE   OF    OPERATING    FOR    POLYPI. 

should  not  hold  the  end  of  it  whilst  he  tightens  the  ligature ;  lest 
with  the  force  used,  the  ligature  should  cut  through  the  neck  of  the 
tumour,  and  the  other  extremity  of  the  cannula  should  be  forcibly 
and  suddenly  pushed  by  the  left  hand  against  the  internal  parts 
of  the  woman.  In  order  to  avoid  this  accident,  the  cannula 
should  be  firmly  held  close  to  the  external  parts  of  the  woman, 
which  prevents  the  possibility  of  mischief  being  done.  If  the 
cannula  with  a  ligature  is  employed,  it  is  next  to  impossible  that 
this  accident  should  happen. 

"A  syringeful  of  warm  water  should  be  thrown  into  the  vagina 
every  day,  when  the  ligature  is  tightened,  in  order  to  wash  away 
the  putrid  discharge. 

"  The  time  at  which  the  ligature  will  come  away,  will  depend 
.upon  the  thickness  and  firmness  of  the  neck  of  the  tumour,  and 
the  tightness  with  which  the  ligature  is  at  first  applied.  The 
neck  of  the  tumour  sometimes  is  cut  through  in  four  days ;  some- 
times ten  or  twelve  days  will  elapse  between  the  application  of 
the  ligature  and  the  removal  of  the  tumour,  and  occasionally  the 
separation  of  the  tumour  will  take  up  nearly  three  weeks,  but 
this  is  an  uncommon  occurrence. 

"The  neck  of  the  tumour  being  destroyed,  the  tumour  itself 
is  to  be  brought  away  by  the  practitioner.  This  will  be  accom- 
plished in  some  cases  with  ease,  by  one  or  two  fingers  intro- 
duced into  the  vagina.  If  the  polypus  is  large,  or  the  external 
parts  contracted,  a  single  blade  of  a  pair  of  midwife  forceps  may 
be  used.  If  the  size  of  the  tumour  should  be  such  as  not  to  be 
easily  removed  by  these  means,  the  crotchet  may  be  fixed  into 
it,  and  in  this  way  it  may  be  brought  along.  The  palm  of  the 
hand  should  always  be  kept  opposite  to  the  beak  of  the  instru- 
ment: so  that  if  it  should  slip,  the  parts  of  the  woman  may  not 
be  injured  by  it. 

"  The  cavity  of  the  vagina  should  afterwards  be  cleansed,  by 
injecting  some  tepid  water,  and  this  should  be  repeated  during 
severaf  days. 

"  The  mucous  and  bloody  discharge  seldom  continues  long  after 
the  extraction  of  the  polypus ;  but  if  any  should  remain  after  a 
week  or  ten  days,  some  astringent  injection  should  be  thrown 
into  the  vagina  three  or  four  times  a  day. 

"As  the  ligature  is  applied  around  the  neck  of  the  tumour,  a 
part  of  the  latter  may  remain  between  the  ligature  and  the  uterus. 
In  consequence  of  the  application  of  the  ligature,  this  part  putre- 
fies, and  comes  away  mixed  with  the  discharges.  In  one  case 
in  which  the  author  extracted  a  polypus  from  the  uterus,  he  found 
that  the  os  uteri  had  nearly  recovered  its  natural  size  at  the  end  of 
five  days  from  the  time  at  which  the  ligature  came  away ;  that 
at  the  end  of  fourteen  days  it  was  impossible  to  ascertain  that 


CAULIFLOWER  EXCRESCENCE.        275 

any  disease  had  existed  in  the  parts ;  and  upon  the  sixteenth  day, 
the  patient  menstruated. 

"  It  has  been  recommended,  after  the  application  of  the  liga- 
ture, that  the  tumour  should  be  cut  off  with  a  knife ;  but  there 
does  not  appear  to  be  any  necessity  for  doing  this,  particularly 
as  no  harm  arises  to  the  patient  from  suffering  it  to  remain  till  it 
falls  off.  Besides  which,  mischief  might  be  done  with  a  knife 
carried  high  into  the  vagina,  and  it  is  by  no  means  certain  that 
the  tumour  will  not  be  more  likely  to  return. 

"It  sometimes  happens  that  the  ligature  and  cannula  fall  out  of 
the  vagina  when  the  practitioner  is  not  with  the  patient ;  for 
which  event  she  should  be  prepared,  lest  this  occurrence  should 
create  alarm.  Whenever  this  happens,  it  is  obvious  that  the  neck 
of  the  tumour  is  destroyed. 

"The  food  of  the  patient  should  be  simple,  easy  of  digestion, 
and  nutritious.  If  the  bowels  should  be  confined,  a  clyster  of 
warm  gruel  may  be  thrown  into  the  rectum.  If  the  stomach 
should  be  irritable,  a  saline  draught  in  a  state  of  effervescence 
may  be  given,  with  a  few  drops  of  laudanum ;  and  if  the  patient 
should  complain  of  pain  from  long  confinement  to  the  same  pos- 
ture, a  sufficient  dose  of  opium  should  be  taken  to  procure  rest. 

"  The  cause  of  debility  being  removed,  the  patient  generally 
quickly  recovers  her  strength ;  but  as  an  auxiliary,  a  draught  con- 
sisting of  a  decoction  of  bark,  with  sulphuric  acid,  may  be  taken 
three  times  a  day." 

SECT.  V. — Of  the  Cauliflower  Excrescence. 

This  is  a  disease  of  the  uterus  that  the  author  has  not  seen. 
He  has,  in  several  instances,  witnessed  considerable  discharges 
of  a  watery  kind  from  the  vagina,  which  he  anticipated  might  be 
this  disease ;  but  upon  examination  per  vaginam,  they  did  not 
prove  to  be  so ;  nor  could  the  cause  of  such  profuse  discharges 
be  accounted  for:  they  all  were  relieved  by  astringent  injections, 
the  tincture  of  cantharides,  the  bals.  copaiv.,  &C.1 

1  I  lately  witnessed  a  case  of  profuse  and  acrid  discharge  of  water  from  the  va- 
gina, which  resisted  all  the  remedies  I  employed,  and  eventually  terminated  in 
death.  The  neck  of  the  uterus,  when  examined  per  vaginam,  was  much  thickened, 
tender,  and  opened  so  much  as  to  permit  the  finger  to  pass.  The  whole  uterine 
mass  seemed  to  fill  up  the  lower  portion  of  the  pelvis,  and  appeared  to  be  attached 
to  the  whole  of  the  surrounding  parts,  so  firmly,  as  to  be  immovable  in  the  pelvic 
cavity,  by  any  force  which  could  be  applied  by  the  finger.  There  was  also  a  con- 
siderable hemorrhage  from  time  to  time;  and  when  this  was  not  present,  the 
watery  discharge  was  constant  and  copious.  The  patient  appeared  to  sink  from 
the  profuseness  of  this  discharge.  She  laboured  under  this  complaint  about  six 
months.  Leave  could  not  be  obtained  to  inspect  the  body. 

There  was  not,  at  any  time  of  her  illness,  any  rising  of  the  fundus  above  the 
pelvis;  or,  in  other  words,  there  was  no  distention  of  this  organ,  to  lead  to  the 
suspicion  that  its  cavity  might  be  occupied  by  hydatids. 


276  CAULIFLOWER    EXCRESCENCE. 

The  late  Dr.  John  Clarke,  of  London,1  we  believe,  was  the 
first  who  described  this  disease.  In  this  country  it  must  be  ex- 
tremely rare,  or  our  experience,  we  think,  would  have  furnished 
us  with  a  case.  It  may  almost  be  looked  upon  as  among  the  in- 
curable diseases  of  these  parts,  though  considerable  relief  has 
been  experienced,  at  different  times,  by  the  application  of  the 
ligature,  &c. 

This  disease  has  taken  its  name  from  its  strong  resemblance 
to  the  cauliflower.  "  The  surface  is  granulated,  and  it  consists 
of  a  great  number  of  small  projections,  which  may  be  picked  off 
from  the  surface,  as  the  granules  may  be  detached  from  the  ve- 
getable." Clarke,  p.  59.  The  whole  of  this  excrescence  is  co- 
vered by  a  membrane  of  an  extremely  fine  texture :  from  the  sur- 
face of  which  an  aqueous  fluid  is  poured  in  great  quantity;  and 
thus  gives  a  particular  character  to  this  disease. 

This  tumour  occupies,  for  a  long  time,  the  upper  part  of  the 
vagina,  as  it  is  the  product  of  the  os  uteri ;  it,  however,  gradually, 
nay,  sometimes  very  rapidly,  enlarges  so  much  as  to  fill  up  the 
whole  of  the  vaginal  cavity;  and  occasionally  even  to  protrude 
beyond  the  labia.  This  extension  of  the  disease  gives  an  oppor- 
tunity to  examine  its  texture,  and  to  ascertain  its  colour. 

Its  texture  is  so  extremely  delicate  as  to  be  injured  by  the 
slightest  violence ;  and  when  this  has  been  done,  a  discharge  of 
florid,  arterial-looking  blood,  immediately  follows ;  the  quantity 
of  which  will  be  in  proportion  to  the  extent  of  lesion  the  tumour 
may  have  suffered. 

The  appearance  of  the  tumour  is  of  a  bright  flesh  colour; 
giving  evidence  of  great  vascularity,  with  very  little  solidity  of 
structure. 

This  tumour  possesses  no  sensibility,  and  is  one  of  the  rare  in- 
stances of  great  vascularity  being  unaccompanied  by  exalted 
feeling. 

In  no  instance  is  the  structure  of  the  vagina  involved,  so  far 
as  observation  has  yet  extended.  It  may  originate  from  the 
whole  circle  of  the  os  uteri,  or  only  from  a  portion  of  it :  hitherto 
it  has  never  been  traced  within  the  uterus. 

Mr.  Clarke  thinks  the  growth  of  this  excrescence  is  in  some 
measure  influenced  by  the  capacity  of  the  vagina;  increasing 
more  rapidly  in  capacious  than  in  restricted  vaginae.  Hence 
in  married  women  who  have  borne  many  children,  the  tumour 
increases  very  rapidly;  and,  on  the  contrary,  "the  pressure  of 
the  sides  of  a  less  capacious  vagina,  as  in  single  women,  will 
greatly  tend  to  control  its  enlargement,  acting  like  a  bandage.' 
—Clarke,  p.  61. 

1  See  his  paper,  in  Transactions  of  the  Society  for  the  Improvement  of  Medical 
Knowledge,  1812. 


CAULIFLOWER    EXCRESCENCE.  277 

It  would  seem  that  the  enlargement  of  the  tumour,  at  least, 
when  it  is  so  large  as  to  protrude  beyond  the  labia,  occasions 
inconvenience  by  its  mechanical  pressure ;  as  the  parts  immedi- 
ately in  contact  with  it  will  not  unfrequently  ulcerate. 

It  is  not  ascertained  what  gives  rise  to  this  disease;  conjec- 
ture even  seems  at  bay.  The  mechanical  violences  of  labour, 
are  altogether  insufficient  to  account  for  its  production;  for 
"married  women,  who  have  never  been  pregnant;  nay,  single 
women,  are  liable  to  the  complaint,  in  whom  no  violence  can 
have  been  offered  to  the  os  uteri,"  p.  62. 

"  It  cannot  be  traced  to  any  syphilitic  cause.  The  common 
prostitutes  of  this  metropolis,  (London,)  are  by  no  means  more 
liable  .to  it,  than  any  similar  number  of  women  in  different  sta- 
tions of  life.  The  disease  as  often  arises  in  the  strong  and  robust 
as  in  the  weak ;  in  persons  who  live  in  the  country,  as  those 
who  inhabit  large  towns;  in  those  whose  situation  in  life  obliges 
them  to  labour,  as  well  as  in  those  who,  from  their  rank  in  so- 
ciety, sometimes  consider  themselves  privileged  members  of  it. 

"No  period  of  life,  after  the  age  of  twenty,  seems  to  be  exempt 
from  the  disease.  The  author  has  known  it  fatal  at  the  age  of 
twenty ;  and  he  has  met  with  the  disease  at  different  periods  of 
life  up  to  old  age." — Clarke,  p.  62. 

We  have  noticed  above,  that  the  blood  which  escapes  from  the 
tumour,  when  it  has  been  injured,  has  the  marks  of  arterial 
blood;  indeed  this  excrescence  seems  to  be  but  a  mass  or  con- 
geries of  arteries  and  veins. 

A  very  remarkable  circumstance  attends  this  disease;  namely, 
its  disappearance  after  death.  Mr.  Clarke  declares,  "  No  one 
has  seen  a  tumour,  resembling  a  cauliflower  excrescence,  in  the 
dead  body,"  p.  63.  It  seems  that  so  soon  as  life  ceases,  the 
whole  tumour  shrinks,  and  leaves  nothing  which  resembles  itself. 
AH  that  can  be  perceived  of  the  former  tumour,  however  large 
it  may  have  been,  is  "  a  soft,  flaccid,  slimy,  whitish  substance, 
resembling  the  foetal  portion  of  the  placenta  of  a  calf,  after  it 
has  been  macerated  in  water,"  p.  66. 

Notwithstanding  the  extremely  vascular  nature  of  this  excres- 
cence, it  has  hitherto  resisted  every  attempt  to  inject  it ;  and, 
"though  the  uterine  vessels  were  abundantly  filled  with  the  in- 
jection, the  fluid  escaped  from  its  surface  as  fast  as  it  was  thrown 
in  from  the  pipe  of  the  injecting  syringe. 

Many  attempts  have  been  made  by  different  practitioners  to 
procure  a  specimen  of  this  disease ;  but  all  had  failed,  until  Mr. 
Clarke  was  fortunate  enough  to  remove  one  of  these  tumours  on 
the  third  day  after  the  application  of  a  ligature.  So  soon  as  it 
was  relieved  from  the  vagina,  it  was  put  into  alcohol :  it  was 
from  this  specimen  that  his  beautiful  drawing  and  engraving 
were  made.  See  plate  IX. 


278      SYMPTOMS   OF    CAULIFLOWER   EXCRESCENCE. 


SECT.  VI. — Of  the  Symptoms  of  this  Complaint. 

This  complaint  begins  by  an  aqueous  discharge  from  the  va- 
gina: this  is  but  little  attended  to  in  the  beginning;  nor,  indeed, 
until  the  quantity  rendered  obliges  the  woman  to  protect  herself 
against  its  excess.  But  as  this  profusion  is  not  attended  with 
either  pain  or  stench,  she  neglects  herself,  until  her  health  yields 
to  this  undermining  disease.  As  a  general  rule  the  quantity  of 
watery  discharge  is  in  proportion  to  the  surface  of  the  tumour. 

The  water  evacuated  in  this  way  may  be  altogether  transpa- 
rent or  colourless,  or  only  occasionally  tinged  with  red,  upon 
the  yielding  of  a  small  vessel :  the  quantity  of  water  may  be  so 
small  as  not  to  create  any  great  inconvenience,  or  it  may  be  so 
excessive  as  to  require  constant  attention.  Sexual  intercourse 
is  always  followed  by  a  discharge  of  blood;  even  common  exer- 
tions may  be  succeeded  by  a  similar  hemorrhage.  Thus,  cough- 
ing, sneezing,  or  straining  at  stool,  will  sometimes  be  followed 
by  a  great  loss. 

The  watery  discharge  diminishes  in  proportion  as  the  san- 
guineous increases.  From  these  multiplied  discharges  the  sys- 
tem becomes  very  much  debilitated,  and  the  body  wastes,  but 
not  to  great  emaciation ;  the  stomach  becomes  dyspeptic,  and 
the  belly  tympanitic.  Hysterical  and  nervous  symptoms  super- 
vene, to  aggravate  the  distresses  of  the  already  oppressed  pa- 
tient. 

Effusions  now  take  place,  and  both  local  and  general  dropsy 
but  too  certainly  follow.  Sometimes  the  sufferings  of  the  patient 
have  an  unexpected  and  fatal  termination,  from  the  profuseness 
of  the  hemorrhage  which  may  have  suddenly  assailed  her. 


SECT.  VII. — Of  the  Prognosis. 

Mr.  Clarke  is  of  opinion  that  the  tonicity  of  the  vagina  will 
have  a  decided  influence  upon  the  progress  of  this  complaint; 
which  must  consequently  influence  the  prognosis.  He  says, 
"As  the  enlargement  of  vessels  in  other  situations  is  much  in- 
fluenced by  pressure,  so  it  will  be  found  that  the  compression  of 
the  sides  of  the  vagina  will  greatly  retard  the  growth  of  this  tu- 
mour. Now,  as  the  quantity  of  the  watery  discharge  depends 
upon  the  extent  of  surface  the  tumour  presents,  and  as  the  danger 
of  the  patient  is  in  proportion  to  the  quantity  of  the  discharge,  it 
follows  that  whenever  the  vagina  has  lost  its  tone,  and  the  tu- 
mour has  thereby  been  little  subject  to  compression,  the  prognos- 
tic to  be  given  to  the  friends  of  the  patient,  as  to  the  probable 


TREATMENT    OF    CAULIFLOWER    EXCRESCENCE.    279 

duration  of  life,  should  be  less  favourable  than  when  the  sides  of 
the  tumour  are  supported  by  the  sides  of  a  more  contracted  canal. 
Added  to  this,  the  very  pressure  of  a  contracted  vagina  is  an 
evidence  that  the  constitution  still  possesses  a  considerable  de- 
gree of  vigour:  so  that  the  capacity  of  the  vagina,  in  this  in- 
stance, as  well  as  in  many  others,  is  by  no  means  a  bad  criterion 
of  the  strength  remaining  in  the  constitution. 

"When  the  tumour  occupies  only  a  small  part  of  the  os  uteri, 
the  opinion  to  be  given  should  be  more  favourable,  than  when 
the  whole  circumference  of  the  opening  is  involved  in  the  disease." 
"The  symptoms,  in  some  cases  of  the  disease,  are  diminished 
more  easily  than  others;  of  which  circumstance  no  knowledge 
can  be  obtained  until  the  experiment  has  been  made;  the  greater 
the  effect,  therefore,  which  local  remedies  produce  in  controlling 
the  discharge,  the  longer  will  the  disease  continue,  caeteris  pari- 
bus,  without  destroying  life." 


SECT.  VIII. — Treatment  of  the  Cauliflower  Excrescence. 

This  disease,  like  some  others  of  the  uterus,  if  let  alone,  never 
cures  itself.  The  debilitating  nature  of  the  discharges  with 
which  this  complaint  is  always  attended,  will  soon  exhaust  the 
woman  that  may  be  the  subject  of  them — the  watery  from  the 
excess  of  its  quantity,  and  the  sanguineous  from  the  importance 
of  its  quality,  though  it  may  not  be  profuse.  Unfortunately,  this 
complaint,  in  its  commencement,  does  not  excite  as  much  alarm 
as  its  mischievous  tendency  should  create.  It  were  desirable 
that  females  should  be  better  acquainted  with  the  symptoms 
which  forerun  and  accompany  many  of  the  dangerous  diseases  to 
which  they  are  unavoidably  liable,  were  it  always  safe  to  com- 
municate to  them  such  information.  But,  unfortunately,  the 
imagination  exerts  such  influence  over  the  happiness  of  mankind, 
as  to  render  it  extremely  doubtful,  whether  more  would  not  be 
lost  than  gained  by  such  knowledge :  it  must,  therefore,  be  left 
to  contingent  discovery  for  the  present,  as  it  has  been  hereto- 
fore. 

From  the  nature  of  the  formation,  or  rather  organization,  of 
this  species  of  tumour,  it  is  evident  that  its  extension  or  diminu- 
tion will  very  much  depend  upon  the  state  of  the  circulating  sys- 
tem both  as  regards  its  excitement,  and  its  quantity  of  blood : 
and  experience  appears  to  have  proved  that  nothing  keeps  it  in 
subjection  like  controlling  the  force  of  the  arterial  system ;  and 
nothing  is  so  effectual  to  this  end,  as  lessening  the  quantity  of 
blood ;  directly,  by  bleeding ;  and  preventing  its  accumulation 
by  a  well-regulated  diet. 

Blood  may  be  abstracted  from  the  arm  by  the  lancet;  or  it 


280  TREATMENT    OF    CAULIFLOWER    EXCRESCENCE* 

may  be  taken  by  cups,  or  by  leeching,  from  about  the  sacrum  or 
thighs  :  this  will  diminish  the  quantity  of  blood  immediately  pre- 
sent, and  will  afford  relief.  But  this  benefit  will  be  transient,  if 
new  accumulations  be  not  prevented,  by  severely  restricting  the 
patient  to  a  very  bland  and  unnutritious  diet.  The  articles  of 
diet  must  be  not  only  void  of  stimulus,  but  should  also  be  but 
little  nourishing.  If  this  be  not  attended  to,  no  good  can  result 
from  the  abstraction  of  blood ;  on  the  contrary,  it  may  be  even 
injurious,  as  the  excitability  of  the  system  is  increased  by  the 
loss  of  it. 

Mr.  Clarke  appears  to  prefer  local  to  general  bleeding.  He 
also  prefers  cupping,  to  the  application  of  leeches ;  but  without 
assigning  any  reason  for  the  preference:  we  cannot  see  why 
either  would  not  do. 

,  Mr.  Clarke  says,  "  The  diet  should  be  of  the  mildest  kind,  such 
as  puddings,  white  fish,  and  vegetables."  In  this  country,  we 
should  look  upon  "puddings  and  white  fish,"  as  very  substantial 
fare ;  and  would  be  far  from  the  articles  we  should  select  as  pro- 
per for  a  woman  in  this  situation.  Were  we  to  direct  upon  such 
an  occasion,  we  would  confine  the  patient  to  black  tea,  thin  cof- 
fee, and  stale  bread,  for  the  meals  of  morning  and  evening ;  and 
vegetables  alone  for  dinner.  These  may  consist  of  rice,  the  po- 
tato, the  turnip,  the  parsnip,  the  carrot,  the  tomato,  and  the  ripe 
fruits  of  the  season. 

We  might  permit  a  little  variety,  by  allowing  rennet-whey, 
butter-milk,  baked  or  roasted  apples,  thin  vegetable  jellies,  as 
that  of  the  tapioca,  rice,  or  arrow  root.  Her  drink  should  ab- 
solutely be  water,  barley  water,  molasses  and  water,  toast  water, 
or  thin  flaxseed  tea. 

A  recumbent  posture  must  also  be  insisted  on,  or  but  little 
advantage  will  be  derived  from'  the  attempts  made  to  reduce  the 
force  of  the  circulation.  But  it  should  be  remembered,  that  it  is 
not  a  matter  of  indifference  on  what  the  patient  reposes ;  it  should 
be  either  a  good  elastic  mattress,  a  sacking  bottom,  or  a  sofa.  A 
feather  bed  would  be  directly  injurious,  by  maintaining  too  much 
warmth  about  the  pelvis.  And  Mr.  Clarke  insists,  that,  "if  the 
patient  be  married,  she  should  be  separated  from  her  husband's 
bed;  to  which  she  should  never  return." 

An  unceasing  attention  should  be  paid  to  the  state  of  the 
bowels  ;  a  loose  stool  should  be  procured  daily.  When  this  can  be 
effected  by  diet,  it  is  always  best  it  should  be.  For  this  purpose, 
the  bread  which  the  patient  eats  should  be  made  of  unbolted 
wheat  flour;  or  this  may  be  made  into  mush,  and  eaten  with 
molasses.  Indian  meal  gruel,  sweetened  with  molasses,  has  also 
a  favourable  effect  upon  the  bowels. 

But  should  these  be  found  insufficient  for  the  purpose,  the  pa- 
tient may  chew  daily  a  little  of  the  root  of  rhubarb ;  or  take  equal 


TKEATMENT    OF    CAULIFLOWER    EXCRESCENCE.   281 

parts  of  cremor  tartar  and  the  flower  of  brimstone,  made  into  an 
electuary  by  molasses.  The  lenitive  electuary  alone,  or  a  little 
increased  in  power,  if  necessary,  by  a  small  addition  of  powdered 
jalap,  is  oftentimes  very  effectual.  Equal  parts  of  calcined 
magnesia,  and  the  flower  of  brimstone,  is  a  very  certain  laxative. 
The  solution  of  the  sulphate  of  magnesia,  in  small  doses,  taken  be- 
fore breakfast,  is  also  very  certain.  At  all  events,  costiveness 
must  be  avoided.  Should  it,  however,  accidentally  occur,  it 
should  be  removed  in  the  most  gentle  manner ;  for  the  strong 
efforts  of  the  abdomen  must  be  avoided.  This  will  be  best  done 
by  very  mild  injections,  such  as  warm  molasses  and  water,  thin 
soap  suds  making  the  quantity  such  as  will  ensure  their  opera- 
tion, rather  by  their  bulk  than  their  stimulus. 

Mr.  Clarke  speaks  in  high  terms  of  cold  applied  to  the  outside 
of  the  pelvis;  and  by  injections  of  cold  fluids  within  the  vagina. 
The  former  to  be  applied  by  sponges,  and  the  latter  by  the  female 
syringe :  these  to  be  repeated  twice  each  twenty-four  hours. 

With  a  view  to  diminish  the  size  of  the  tumour,  Mr.  Clarke 
recommends  astringent  applications.  For  this  purpose,  he  ad- 
vises the  sulphate  of  zinc,  in  the  proportion  of  four  or  five  grains 
to  the  ounce  of  water ;  or  alum,  in  the  proportion  of  ten  or  twelve 
grains,  with  a  little  of  the  mucilage  of  gum  Arabic ;  or  alum  and 
the  tincture  of  kino,  as  follows : — 

R.  Infus.  lini,        gxv. 
Aluminis,          3;ij. 
Tinct.  kino,      |j.— M. 

Or, 

R.  Cupri  sulphat.          grg.  x. 
Aquae  FJor.  sarab. 
Mist-  camphorae,     §vj. — M. 

He  gives  several  other  formulae,  much  of  the  same  character, 
but  we  think  of  no  more  efficacy.  He  suggests,  with  much  pro- 
priety, the  necessity  of  great  care  in  throwing  up  these  injections 
into  the  vagina,  lest  the  extremity  of  the  pipe  should  break  a  por- 
tion of  the  tumour,  and  occasion  a  bleeding.  The  round-headed 
pewter  female  syringe  is  the  best  for  this  purpose ;  and  even  this 
should  be  introduced  but  a  little  way  beyond  the  os  externum. 

If  the  tumour  has  so  far  increased  as  to  appear  at  the  os  ex- 
ternum, or  just  within  the  labia,  it  is  advised,  that  the  astringent 
fluids  should  be  used  by  means  of  a  common  earthen  butter 
boat;  the  woman  having  her  hips  elevated  during  the  operation. 
And  when  the  tumour  has  actually  protruded,  Mr.  Clarke  directs 
"compresses  dipped  in  an  astringent  fluid  to  be  applied  to  it; 
or  the  surface  may  be  lightly  touched  with  a  soft  sponge  wetted 
with  it,"  p.  98. 


282    TREATMENT   OF   CAULIFLOWER   EXCRESCENCE. 

As  this  complaint  is  sure,  sooner  or  later,  to  be  attended  by 
great  debility,  the  woman  should  be  supported  by  tonics  when 
this  occurs.  The  sulphuric  and  muriatic  acids  are  recommended 
for  this  purpose,  with  the  infusion  of  orange  peel,  or  of  rose 
leaves,  with  great  confidence,  and,  we  believe,  justly :  at  least 
we  think  they  agree  better  than  any  other  tonics  we  have  tried, 
in  wasting  diseases. 

Bark  in  decoction,  is  also  a  favourite  remedy  with  most  prac- 
titioners, but  it  is  sometimes  difficult  to  restrain  its  effects  on  the 
bowels.  The  sulphate  of  quinine  has  not  the  same  tendency  to 
pass  through  the  bowels,  as  the  bark,  in  substance  or  in  decoc- 
tion; it,  therefore,  merits  the  preference.  The  decoction  of  the 
cascarilla,  (cortex  eleuth.)  has  an  admirable  effect  sometimes, 
where  the  bark  is  indicated  but  cannot  be  used. 

Of  the  general  plan  of  treatment  now  laid  down,  Mr.  Clarke 
speaks  in  the  following  terms.  "  The  author  is  justified  in  re- 
peating that,  by  a  strict  attention  to,  and  compliance  with,  the 
rules  above  suggested,  nearly  every  case  of  this  disease  may  be 
made  tolerable ;  and,  perhaps,  such  a  change  wrought  in  the  size 
or  the  actions  of  the  excrescence,  in  a  few  instances,  as  to  re- 
move all  the  symptoms,"  p.  104.  He  confirms  these  hopes  by 
the  recital  of  several  successful  cases. 

The  ligature,  however,  he  considers  as  an  important  auxiliary. 
It  is  to  be  applied  as  recommended  for  the  polypus  of  the  uterus. 
He  declares,  however,  that  more  care  is  necessary  in  its  appli- 
cation in  the  one  case  than  in  the  other ;  the  cauliflower  excres- 
cence being  so  very  liable  to  bleed,  when  any  violence  is  offered 
it.  The  shield  recommended  for  the  polypus  is  not  so  necessary 
in  the  cauliflower  excrescence,  as  the  tumour  will  be  cut  through 
in  a  much  shorter  time.  The  objection  to  the  use  of  the  shield 
in  this  operation  is  the  possibility  that  the  weight  of  it  may  tear 
through  the  tumour  before  the  blood  has  coagulated  in  the  ves- 
sels above. 

"  After  the  removal  of  the  disease,  (tumour,)  it  is  recommended 
that  the  vagina  should  be  washed  out  with  cold  water,  and  that 
a  solution  of  alum,  in  a  strong  decoction  of  oak  bark,  should  be 
thrown  into  the  vagina  twice  or  three. times  a  day,  and  the  ex- 
ternal orifice  blocked  up  with  a  dossil  of  lint,  so  as  to  prevent 
the  too  sudden  escape  of  the  fluid. 

"  A  weak  solution  of  the  nitrate  of  silver,  or  of  the  sulphate 
of  copper  may  be  preferable,  in  some  instances,  to  any  other  in- 
jection: it  may  be  used  in  the  following  proportions : — 


R.  Argenti  nitrat.  grs.  xij. 

Aq.  distillat.  3X'J-  ^  s0^ 

Or, 

R.  Cupri  sulphat.  grs.  xviij. 

Aquae  rosae,  ox'J-  ^  s°l-" 


HYDATIDS  OF  THE  UTERUS.         283 

A  piece  of  lint,  wetted  with  either  of  these  solutions,  may  be 
introduced,  and  placed  against  the  diseased  portion  of  the  os 
uteri.  "By  such  means,  a  slight  inflammation  may  be  excited 
in  the  blood  vessels,  so  as  to  produce  a  consolidation  of  the  parts 
diseased;  and  thus  the  regeneration  of  the  tumour  may  be  more 
tardy. 

"  However  favourable  appearances  may  be  in  that  part  of  the 
uterus  which  can  be  examined  by  the  finger,  there  may  exist  out 
of  reach,  and  consequently  without  the  knowledge  of  the  practi- 
tioner, morbid  changes  of  structure,  which  may,  of  themselves, 
prove  fatal,"  p.  112. 

We  have  chosen  to  quote  the  opinions  of  Mr.  Clarke  upon  the 
subject  before  us  pretty  much  at  large,  as  his  experience  quali- 
fies him  to  give  directions  for  the  management  of  this  disease, 
which  our  entire  ignorance  would  not  justify.  The  high  stand- 
ing of  this  gentleman,  as  a  successful  practitioner,  adds  much 
value  to  his  practical  directions,  and  what  enhances  these  opi- 
nions still  more  is,  that  they  are  altogether  free  from  learned 
parade  without  elucidation ;  and  of  ingenious  speculations  with- 
out practical  improvement. 


SECT.  IX.— Of  Hydatids  of  the  Uterus. 

By  hydatids  is  understood  a  congeries  of  vesicles  of  various 
sizes,  containing  a  transparent  lymph;  attached  to  the  internal 
face  of  the  uterus,  and  with  each  other,  by  filamentous  footstalks, 
much  resembling  a  bunch  of  grapes.  These  vesicles  differ  in 
size,  from  the  smallness  of  a  pin's  head,  to  the  size  of  a  walnut. 
They  are  looked  upon  as  animals  of  extremely  simple  organiza- 
tion, and  functions.1  Of  their  origin  we  know  nothing,  and 

1  This  disease  has  been  long  known  to  physicians ;  for  it  is  said  that  ^Etius 
has  distinctly  alluded  to  it,  yet  the  cause,  and  the  precise  nature  of  the  product, 
is  still  unsettled.  Valesneri  looked  upon  this  product  as  an  enlargement  of  glo- 
bules or  pouches,  which  he  says  he  has  discovered  by  the  microscope  to  belong  to 
the  lymphatic  vessels  of  the  placenta,  chorion  and  amnios,  as  a  natural  arrange- 
ment; but  which,  from  some  morbid  cause,  have  enlarged  themselves.  Desor- 
meaux,  aided  by  the  microscopical  observations  of  Velpeau,(a)  has  taken  nearly 
the  same  view  of  the  subject  as  Valesneri;  while  Percy  looks  upon  them  as  ani- 
mals, and  to  be  the  tnenia  hydatigena  of  Pallas,  and  declares(i)  lhat  he  has  seen 
them  move,  when  exposed  to  the  action  of  salt  and  vinegar.  While  Madame 
Boivin(c,)  reverts  to  the  old  doctrine,  that  the  vesicular  mole,  as  she  terms  it,  does 
not  consist  of  hydatids,  but  is  bona  fide  a  degeneration  of  the  impregnated  ovum. 
For  she  declares  that  this  vesicular  cluster  is  covered  by  a  membranous  expan- 

(a)  Nouvelles  Reclierchcs,  sur  1'orgine,  fcc. 
(6)  Diet,  de  M6decine,  Art.  CEuf.  Vol  XV. 
(c)  Contort,  Journ.  de  M6dtcine.  XXII.  197. 


284  HYDATIDS    OF    THE    UTERUS. 

almost  as  little  of  their  habits.  Nor  do  we  know  how  many 
species  there  may  be  of  them,  as  several  are  sometimes  found  in 
the  same  animal.  A  large  hydatid  has  several  small  ones  attached 
to  it,  by  small  filamentary  processes. 

These  animals  sometimes  increase  with  great  rapidity;  and 
•when  their  seat  is  in  the  cavity  of  the  uterus,  they  distend  it  in 
proportion  as  they  acquire  size,  or  increase  in  number. 

The  symptoms  of  this  disease  resemble  very  much  those  of  in- 
cipient pregnancy— after  awhile  the  uterus  enlarges,  sometimes 
more,  and  at  other  times  less  rapidly,  and  may  be  felt  in  the  hy- 
pogastrium — swelling  of  the  mammae  most  generally,  together 
with  the  formation  of  a  fluid,  which  may  be  discharged  by  the 
nipples — and  areolae,  as  in  true  pregnancy — sometimes  an  alter- 
nate discharge  from  the  vagina,  of  serum  or  blood ;  and  the  ab- 
sence of  a  solid  body  immersed  in  a  fluid,  as  takes  place  in  preg- 
nancy, when  the  woman  is  examined  by  the  touch.  This  last 
sign,  when  united  with  the  rational  signs  of  pregnancy,  Madame 
Boivin  considers  as  highly  characteristic  of  the  disease.  And 
after  the  expulsion  of  this  body,  lochia  follow,  the  breasts  swell, 
and  milk  is  secreted. 

The  cause  of  the  disease  under  consideration  has  never  been 
discovered.  These  animals  sometimes  attack  the  external  cover- 
ing of  the  ovum,  and  thus  produce  abortion.1  See  note  below. 

It  is  not,  however,  ascertained  that  pregnancy  is  always  ne- 
cessary for  their  production.2  Indeed,  in  the  only  case  we  ever 
witnessed  of  this  disease,  it  certainly  was  not  immediately  so,  if 
reliance  can  be  placed  upon  the  general  good  character  of  the 
patient.  The  patient  was  more  than  thirty  years  of  age,  and  had 
been  a  widow  upwards  of  three  years,  when  she  was  attacked 
with  hydatids  of  the  uterus. 

She  observed  herself  to  swell  gradually,  and  also  to  decline  in 
health;  her  menses  were  arrested,  and  her  lower  extremities 


sion  which  is  divisible  into  two  laminae — one  of  which  resembles  the  epichorion 
or  decidua  reflexa,  while  the  other  differs  in  nothing  from  the  amnios. 

1  A  case  of  this  kind,  with  a  drawing  of  the  ovum,  has  been  kindly  furnished 
me  by  Dr.  Atlee  of  this  place,  accompanied  by  the  following  account  of  it. 

"  The  above  is  a  rough  drawing  of  an  ovum  beset  with  hydatids,  which  was 
expelled  from  the  uterus  of  a  particular  friend,  aged  about  forty-five  years,  who 
had  had  slight  floodings  every  day,  at  intervals,  for  one  month,  unattended  with 
pain;  at  the  expiration  of  which  time,  labour  pains  came  on,  and  the  ovum  soon 
escaped.  The  rationale  of  the  case  I  have  supposed  to  be  thus:  the  hydatids 
forming  and  increasing  gradually,  separated  by  degrees  the  ovum  from  the  parietes 
of  the  uterus,  at  each  renewed  separation  causing  hemorrhage,  and  soon  the  death 
of  the  embryo,  which,  on  cutting  into  the  ovum,  was  let  out,  in  appearance  like 
pus.  The  hydatids  contained  pure  lymph."  See  Plate  VIII. 

"Mdrne.  Boivin  and  some  others,  think  that  impregnation  is  essential  to  the 
production  of  the  uterine  bydatid.  Ruysch  thought  that  a  retained  placenta 
would  give  rise  to  hydatids. 


HTDATIDS  OF  THE  UTERUS.          285 

•were  swollen.  Her  friends  suspected  she  was  pregnant ;  and 
when  she  was  attacked  with  periodical  pains,  they  were  certain 
their  conjectures  were  well  founded:  at  this  time  we  were  sent 
for.  Before  our  arrival,  however,  the  uterus  had  relieved  itself 
by  expelling  nearly  a  chamber-potful  of  hydatids ;  at  least  so  we 
supposed  them  to  be ;  for  they  had  been  thrown  out  unfortunately 
before  we  came.1  They  said  what  came  from  her  was  like  a 
very  large  bunch  of  grapes  of  different  sizes ;  from  the  size  of  a 
currant  to  that  of  a  large  fox  grape. 

When  we  arrived,  we  found  the  woman  very  much  exhausted 
by  the  discharge  of  blood,  and  which  was  still  flowing  in  an 
alarming  degree.  This  was,  however,  arrested  by  frictions  upon 
the  abdomen,  ice,  and  large  doses  of  the  acetate  of  lead  and 
opium.  In  the  course  of  two  years  she  had  several  attacks  of 
this  kind,  each  of  which  was  less  severe  than  the  former ;  and  at 
last  they  seemed  to  cease  spontaneously,  and  the  woman  reco- 
vered her  health,  without  any  thing  particular  having  been  done 
for  her,  except  sea-bathing  for  a  whole  season. 

As  connected  with  medical  jurisprudence,  it  would  be  of  the 
highest  importance  to  determine  whether  impregnation  be  a  sine 
qua  non  to  the  production  of  "hydatids — but  whether  this  will 
ever  be  satisfactorily  determined,  must  be  left  to  contingency, 
as  neither  reasoning,  nor  experiment,  can  well  decide  the  ques- 
tion. We  would,  however,  suggest,  that  as  the  opinion  of  Ma- 
dame Boivin  rests  upon  assumption,  as  well  as  that  of  Percy,  a 
jury  should  incline  to  the  side  of  mercy,  when  a  question  of  this 
kind  is  agitated.  We  therefore  altogether  applaud  the  decision 
of  Percy,  who  acquitted  a  young  religieuse  of  incontinence,  by  de- 
claring, that  vesicular  moles  are  merely  hydatids,  though  she 
would  perhaps  have  been  condemned  by  Madame  Boivin,  had 
the  appeal  been  made  to  her.  We  therefore  look  upon  the  hypo- 
thesis of  this  lady,  if  adopted  in  its  full  extent,  to  be  highly  dan- 
gerous, and  must  remain  so,  unless  her  opinion  be  unequivocally 
proved — but,  fortunately,  hydatids  is  a  rare  disease,  and  cannot 
often  compromit  character  or  life. 

In  consequence  of  the  delicacy  of  the  covering  of  the  hydatid, 
it  is  easily  destroyed  by  pressure,  or  any  conquassatory  motion 
of  the  abdominal  muscles  or  uterus :  hence  they  frequently  burst, 
and  give  rise  to  a  discharge  of  a  pale  transparent  fluid,  without 
odour  or  tenacity.  And  this  circumstance  may  be  said  to  be  the 
only  one  which  characterizes  this  complaint;  for  every  other  at- 
tending symptom  is  so  common  to  many  other  affections  of  the 
uterus,  that  they  would  not  serve  to  distinguish  it.  The  greater 
part  of  the  inconvenience  of  this  complaint  arises,  as  in  preg- 

1  "  They  are  known  to  have  remained  in  utero  longer  than  other  kinds  of  moles. 
Duges  relates  a  case  where  15  pounds  weight  of  hydatids  were  discharged,  which 
had  been  five  or  six  years  accumulating," 


286  HYDATIDS    OF    THE    UTERUS. 

nancy,  from  the  pressure  of  the  distended  uterus  upon  the  sur- 
rounding parts :  hence  we  sometimes  have  cramps  of  the  lower 
extremities,  oedematous  swellings  of  them,  retention  of  urine, 
&c.,  as  in  a  genuine  pregnancy.  I  cannot  find,  in  any  memo- 
randa of  the  cases  just  related,  any  notice  taken  of  the  condition 
of  the  mammae  from  this  diseased  occupation  of  the  uterus. 

This  disease  may  be  known  from  the  cauliflower  excrescence, 
by  the  occasional  discharge  of  a  watery  fluid,  and  this  in  differ- 
ent quantities  at  different  times ;  whereas,  in  the  latter  disease, 
the  quantity  of  fluid  discharged  is  much  greater,  and  more  con- 
stant. As  regards  the  sensible  qualities  of  each,  they  perhaps 
resemble  each  other  pretty  strictly;  but  we  know  of  no  experi- 
ments to  determine  their  chemical  resemblances  or  discrepan- 
cies.1 

No  remedy  has  hitherto  been  discovered  for  the  relief  of  this 
complaint.  The  patient  is  not  to.  be  led  to  expect  any  great 
benefit  from  art ;  at  least  in  the  progress  or  in  the  interval  of 
the  disease.  All  it  can  do  is  to  afford  a  degree  of  relief  by 
aiding  in  a  species  of  labour,  which  will  sooner  or  later  take 
place,  from  the  distention  of  the  uterus. 

Percy  declares  that  after  the  discharge  of  vesicles  had  com- 
menced, he  found  great  advantage  from  injecting  a  solution  of 
salt  in  vinegar  into  the  uterus.  He  declares  this  was  followed 
by  a  rustling  noise  in  the  pelvis,  occasioned,  as  he  supposes,  by 
the  agitation  into  which  the  hydatids  were  thrown  by  this  un- 
usual stimulus.  On  this  point  Mdme.  Boivin  declares  her  fear 
of  either  its  utility  or  its  safety,  as  in  one  of  her  own  patients 
threatening  symptoms  of  inflammation  after  its  employment  en- 
sued; and  in  another,  it  was  of  no  advantage.  She  considers 
gentle  titillation  at  the  os  uteri  with  the  finger,  stimulating  in- 
jections per  anum,  frictions  upon  the  hypogastrium,  and  the  ap- 
plication of  cold  to  the  lower  part  of  the  trunk,  to  be  more  effi- 
cacious and  safe.  Injections  into  the  uterus,  of  a  stimulating 
kind,  are  useful,  she  says,  when  it  does  not  contract,  or  if  the 
hemorrhage  continues  after  it  has  contracted.  But  we  are  of 
opinion  that  the  "ergot,"2  as  will  be  recommended  presently, 
would  supersede  all  these  remedies. 

Mr.  Clarke  declares,  "  When  this  period  arrives,  at  which  the 
uterus  is  striving  to  unload  itself  of  its  contents,  then  all  the  skill 
and  energy  of  the  practitioner  will  be  wanting,  and  all  his  efforts 
will  be  called  forth  to  control  the  hemorrhage,  and  to  sustain  the 
powers  of  the  constitution.  With  this  view,  the  patient  should 

1  "They  contain  a  fluid,  which,  in  the  smaller  ones,  is  transparent,  and  in  the 
larger  ones  I  have  seen  them  of  a  beautiful  pink.  It  is  less  dense  than  distilled 
water;  does  not  burn  vegetable  blue,  red;  it  is  not  coagulable  in  either  heat  or 
acids." — Nauche. 

3  We  believe  we  were  the  first  to  recommend  the  "  ergot "  in  these  cases. 


HYDATIDS   OF   THE   UTERUS.  287 

be  kept  perfectly  still,  in  a  horizontal  posture :  she  should  not  be 
allowed  to  take  any  stimulating  food  or  drink.'  Cold  applica- 
tions to  the  loins,  abdomen,  and  external  organs,"  &c.  Treating 
it  as  any  other  case  of  uterine  hemorrhage,  by  promoting,  by 
every  possible  means,  the  contraction  of  the  uterus.  "Should 
any  portions  of  the  hydatid  remain,  and  if  the  hemorrhage  should 
continue  profuse,  an  attempt  should  be  made  to  remove  these,  in 
order  to  produce  complete  contraction  of  the  muscular  fibres." 
Vol.  I.  p.  120. 

This  is  to  be  done  by  introducing  the  hand,  well  lubricated, 
into  the  cavity  of  the  uterus,  and  carefully  detaching  the  adhering 
portions  of  the  hydatids,  and  bringing  them  out  with  the  hand. 
It  will  be  perceived,  that  this  direction  cannot  be  complied  with 
in  all  instances;  for  in  all  instances,  the  uterus  will  not  be  suffi- 
ciently distended  by  the  hydatids  to  permit  the  passing  of  the 
hand  with  ease;  and  violence  must  never  be  employed  in  this, 
or  any  other  instance,  in  passing  the  hand  into  the  cavity  of  the 
uterus. 

We  would  propose,  and  we  think  with  a  fair  prospect  of  suc- 
cess, the  free  use  of  the  secale  cornutum  in  this  complaint,  to  pro- 
cure the  expulsion  of  the  hydatids ;  especially  in  such  cases  as 
would  not  easily  admit  the  hand,  or  where  the  contractions  of 
the  uterus  were  too  feeble,  or  insufficient  for  their  extrusion. 

So  far  as  analogy  and  reasoning  upon  a  subject  will  justify 
the  employment  of  a  novel  remedy,  we  have  them  on  our  side ; 
for  it  is  certain  that  the  union  of  hydatids  with  the  uterus  is  not 
more  strict  than  the  ordinary  connexion  of  the  placenta  with  that 
body ;  and  we  know,  from  experience,  that  this  connexion  may  be 
destroyed,  most  fortunately,  sometimes,  by  this  very  peculiar  and 
interesting  drug.  As  regards  ourselves,  we  shall  not  hesitate  a 
moment  to  employ  it. 

Since  writing  the  above,  I  have  been  favoured  with  a  letter 
from  Mr.  Anderson,  of  Hagerstown,  Maryland,  giving  an  account 
of  the  "  ergot"  in  this  complaint,  which  I  shall  have  much  plea- 
sure in  detailing.  The  trial  of  this  substance  was  made  by  Dr. 
W.  D.  Macgill,  of  the  above  named  place. 

"Early  last  spring,  Dr.  M.  was  called  to  see  Mrs.  W.,  aged 
forty  years,  who  had  previously  enjoyed  good  health,  and  had 
been  the  mother  of  several  children.  She  was  labouring  under 
a  very  painful  affection  of  the  womb,  accompanied  with  periodi- 
cal hemorrhagy,  occurring  once  in  twenty-four  hours,  usually  in 
the  evening,  attended  by  febrile  symptoms,  and  much  disturbance 
of  the  digestive  functions,  and  which  was  evidently  making  rapid 
inroads  upon  her  constitution.  During  its  farther  continuance, 
her  stomach  became  exceedingly  irritable,  so  much  so,  indeed, 
as  scarcely  to  retain  nourishment  of  any  description.  Dr.  M.  ad- 
dressed his  remedies  principally  to  the  restraining  of  the  hemor- 


288  HYDATIDS   OF  THE   UTERUS. 

rhagy,  and  obviating  the  excessive  weakness  of  the  stomach.  But 
notwithstanding,  the  symptoms  continued  to  increase  in  violence, 
so  much  as  to  endanger  the  life  of  the  patient.  She  had  be- 
come very  much  exhausted  by  the  repeated  loss  of  blood,  an  ina- 
bility to  take  food,  '(for  she  had  now  suffered  for  more  than  three 
months,)  when  the  doctor  made  an  examination  per  vaginam, 
(after  having  made  them  frequently  before  without  any  satisfac- 
tory result,)  and  discovered  something  protruding  through  the 
os  uteri,  which  he  extracted,  and  found  that  the  poor  woman  was 
labouring  under  hydatids  of  the  womb.  He  immediately  sent  for 
the  ergot,  judging  from  analogy  that  it  would  prove  decidedly 
effectual  in  producing  an  expulsion  of  the  heterogeneous  mass. 
The  event  proved  that  he  was  not  mistaken  in  his  conjecture ;  for 
he  had  given  the  ergot  but  a  very  few  minutes,  when  it  began  to 
show  its  specific  operation  upon  the  uterus,  and  succeeded  in  a 
complete  evacuation  of  its  contents.  The  mass  of  hydatids 
equalled  in  size  the  head  of  a  large  child  at  birth,  and  afforded  a 
very  good  specimen  of  the  disease,  a  part  of  which  we  have  made 
a  preparation  of.  The  representation  in  your  book  on  the  'Dis- 
eases of  Women,'  is  admirable.  The  floodings  immediately 
ceased,  and  did  not  return.  The  woman  rapidly  recovered,  until 
at  length  she  attained  her  former  health  and  vigour,  and  I  be- 
lieve is  again  pregnant.  She  says  her  mother  died  of  a  disease 
exactly  similar." 

"P.  S. — Dr.  Macgill  had  not  heard  of  your  suggestion  until 
after  the  delivery.  He  was  led  to  the  employment  of  the  ergot 
solely  from  analogy." 

It  seems,  however,  that  the  progress  of  gestation  is  not  always 
interrupted  by  the  presence  of  hydatids,  as  the  following  case 
proves. 

"Mad.  Hec — ,  aged  forty  years,  had  been  plunged  in  misery 
and  distress,  from  her  own  bad  conduct,  for  some  years.  She 
was  subject  to  attacks  of  lipothymia  after  eating.  For  four  months 
the  menses  had  been  wanting,  and  it  was  supposed  that  she  was 
pregnant.  Dr.  T.  examined,  but  could  not  decide  on  this  point. 
The  woman  herself,  who  had  borne  nine  children,  did  not  con- 
sider it  as  pregnancy.  She  believed,  from  the  vomiting  after 
food,  that  she  laboured  under  scirrhus  of  the  stomach,  of  which 
complaint  her  mother  had  died.  Low  diet  and  diluents  were 
prescribed.  There  was  now  developed  much  irritation  about 
the  uterus,  and  leeches  were  applied  to  the  groin  and  vagina. 
The  irritation  was  removed.  The  stomach  complaint  was  now 
much  relieved.  A  month  or  more  after  this,  our  author  was 
hastily  summoned  to  Madame  H.,  who  was  said  to  be  in  labour. 
The  uterus  was  now  much  larger  than  when  last  examined,  and 
seemed  to  fill  the  pelvis.  There  were  bearing-down  pains,  and 
in  these  the  uterus  felt  very  turgid.  The  os  uteri,  however, 


HYDATIDS  OF  THE  UTERUS.          289 

was  close,  and  no  discharge  from  thence.  The  pains  persisted 
without  any  alteration  in  the  cervix  or  os  uteri.  This  state  con- 
tinued three  days  more,  when  it  was  perceived  that  at  each  bear- 
ing-down pain  there  was  some  discharge  of  clear  water.  This 
was  followed,  some  days  afterwards,  by  a  large  number  of  hy- 
datids,  of  various  sizes,  from  an  inch  in  diameter  downwards. 
She  continued  to  pass  these  bodies  for  fifteen  days.  In  the  mean 
time  the  size  of  the  uterus  rapidly  increased,  and  rose  out  of  the 
pelvis.  It  was  now  ascertained  that  there  was  a  foetus  in  utero, 
and  yet  the  hydatids  were  discharged  daily  in  considerable 
quantities.1  Three  or  four  months  after  this  she  was  delivered 
of  a  child  at  the  full  term,  the  hydatids  having  never  ceased  one 
day  to  be  discharged.  There  were  one  hundred  and  forty-eight 
of  these  bodies  collected,  and  the  number  broken  and  unobserved 
could  not  be  estimated.  The  patient  recovered,  and  did  well. 
She  has  since  become  pregnant." 

We  will  give  another  case  of  this  rare  and  interesting  affec- 
tion ;  as  all  that  we  can  learn  of  a  disease  so  uncommon  and  so 
important,  will  fall  short,  perhaps,  of  being  sufficient  to  establish 
its  diagnosis,  and  best  mode  of  treatment.  In  the  case  follow- 
ing, we  are  disposed  to  believe,  that  had  "ergot "  been  duly  ad- 
ministered, it  would  have  been  more  prompt  in  its  action,  and 
less  equivocal  in  its  safety,  than  the  one  pursued — it,  however, 
terminated  well. 

A  woman,  after  being  six  times  pregnant,  imagined  herself 
with  child  for  the  seventh  time,  in  consequence  of  the  cessation 
of  the  catamenia.  Soon  afterwards  she  was  attacked  with  in- 
cessant vomiting,  the  abdomen  increased  rapidly  in  size,  and 
became  tender  to  the  touch ;  the  legs  also  became  oedematous  and 
the  breathing  short.  These  symptoms,  however,  she  conceived 
to  arise  from  twins,  and  she  did  not  apply  for  medical  assistance. 
In  the  fifth  month  of  the  supposed  pregnancy  the  swelling  of  the 
belly  became  rapidly  enormous,  the  oedema  extended  over  the 
trunk,  and  her  respiration  became  very  difficult,  when,  at  length, 
labour-pains  suddenly  set  in,  and  considerable  hemorrhage  en- 
sued, which  was  at  first  checked  by  cold  applications,  but  soon 
afterwards  returned  more  violently.  At  the  same  time  a  large 
mass  of  hydatids,  as  big  as  two  fists,  was  discharged.  The  ac- 
coucheur, who  now  saw  her  for  the  first  time,  found  her  pale, 
fainting,  without  pulsation  at  the  wrist,  and  breathing  slowly  and 
laboriously.  The  fundus  uteri  was  a  hand's  breath  above  the 
navel,  and  the  tumour  formed  by  the  womb  was  regular,  not 
elongated  or  lying  to  one  side,  as  is  usually  the  case  in  this  dis- 
ease. The  os  uteri  was  dilated  to  the  size  of  a  half  dollar,  and 

1  Does  this  case  seem  to  prove,  that  hydatids  do  not  depend  upon  a  diseased 
ovum,  as  suggested  by  Madame  Boivin? 

19 


290  IRRITABLE    UTERUS. 

was  very  tender  to  the  touch.  Masses  of  hydatids  projected  from 
it  into  the  vagina ;  and  there  was  constant  hemorrhage.  The 
treatment  adopted  in  these  circumstances  consisted  in  the  admi- 
nistration of  tincture  of  castor  every  fifteen  minutes,  spirituous 
frictions  of  the  abdomen,  and  the  injection  into  the  uterus  of  a 
solution  of  salt  acidulated  with  vinegar.  In  consequence  the  la- 
bour pains,  which  had  almost  ceased,  were  speedily  renewed,  and 
rapidly  increased  in  strength;  masses  of  hydatids  were  at  the 
same  time  discharged;  and,  ere  long  the  hemorrhage  ab'ated 
considerably.  In  the  course  of  two  hours  the  fundus  uteri  had 
descended  to  within  a  hand's  breadth  above  the  pubis ;  in  the 
course  of  the  day  it  had  descended  still  lower ;  the  hemorrhage 
ceased ;  a  warm  perspiration  broke  out,  accompanied  with  rising 
of  the  pulse,  and  the  patient  soon  recovered.  Milk  appeared  in 
the  breasts  on  the  third  day,  but  receded  again  without  any  bad 
consequence.  The  hydatids  weighed  six  pounds.  They  were 
attached  to  the  remains  of  a  membrana  decidua." 


SECT.  X. — Of  Irritable  Uterus. 

By  the  "irritable  uterus"  we  are  to  understand  a  peculiar  and 
permanent  sensibility  of  this  organ,  but  more,  especially  of  its 
neck,  which  attacks  the  female  about  the  middle  period  of  life, 
or  a  little  beyond  it;  rarely  showing  itself  before  the  five  and 
twentieth  year,  and,  perhaps,  still  less  frequently  after  the  men- 
strual periods  have  passed.  Dr.  Gooch,1  who  has  devoted  an 
excellent  chapter  to  this  subject,  and  was,  as  far  as  we  know,  the 
first  author  who  treated  of  it,  defines  this  disease  to  be  "a  pain- 
ful and  tender  state  of  the  uterus,  neither  attended  by,  nor  tend- 
ing to  produce  change  in  its  structure."  The  latter  part  of  this 
definition  we  do  not  think  exactly  correct,  as  we  have  always 
found  some  change  in  this  part. 

This  morbid  condition  of  the  uterus  shows  itself  by  both  ge- 
neral and  local  disturbances. 

Of  the  G-eneral  Symptoms. — The  general  symptoms  are,  an 
increased  frequency,  and  a  preternatural  firmness  of  pulse.2  This 
frequency  is  commonly  augmented  towards  evening ;  the  skin 
then  becomes  warmer,  and  the  cheeks  are  reddened  by  a  slight 
hectic  blush.  But  the  pulse  is  always  more  frequent  and  corded 
than  natural,  even  in  the  absence  of  the  exacerbation,  but  least 
so  early  in  the  morning.  We  have  never  observed  any  thing 
like  a  regular  rigour  attend  this  complaint,  though  we  have  often 

1  In  his  work,  entitled  "  An  Account  of  some  of  the  most  important  Diseases 
peculiar  to  Women,  by  Rohert  Gooch,  M.  D." 

*  Dr.  Gooch  says,  "  The  pulse  is  soft,  and  not  much  quicker  than  natural,  but 
is  easily  quickened  by  the  slightest  emotion,"  p.  313. 


IRRITABLE   UTERUS.  291 

heard  the  patient  complain  of  chilliness,  before  an  exacerbation 
of  pain,  especially  if  this  were  about  to  prove  violent. 

The  tongue  is  paler  and  whiter  than  natural,  especially  early 
in  the  morning ;  towards  evening  it  reddens  andjbecomes  cleaner ; 
more  or  less  thirst  attends,  particularly  in  the  after  part  of  the 
day.  The  natural  perceptions  of  the  tongue  are  frequently  per- 
verted ;  so  much  so,  sometimes,  as  to  lead  the  patient  to  the  belief 
that  there  is  a  hair  upon  it ;  some  say  that  the  mouth  feels  as  if 
there  was  dry  flour  in  it ;  while  others  declare  the  sensation  re- 
sembles that  of  grease,  &c. 

Headach  almost  always  attends,  and  it  is  generally  the  back 
part  of  the  head  that  suffers :  this,  for  the  most  part,  increases 
as  the  day  advances,  or  as  the  pulse  increases  in  force  and  fre- 
quency. 

The  skin  is  always  dry  while  the  disease  remains  in  full  force ; 
and  its  general  temperature  is  increased,  if  we  except  that  of  the 
hands  and  feet,  which  is  much  below  the  natural  standard,  espe- 
cially the  latter:  we  have  rarely  known  the  febrile  exacerbation 
terminate  in  sweat. 

The  stomach  is  almost  sure  to  suffer  if  the  disease  continue  for 
a  long  time  obstinate,  though  we  have  occasionally  known  it  not 
to  be  implicated  in  the  general  mischief — but  the  latter  circum- 
stance may  be  looked  upon  rather  as  an  exception  to  the  rule ; 
as,  for  the  most  part,  the  appetite  is  impaired  or  very  capricious, 
and  eventually  dyspepsia  becomes  established.  The  bowels  are 
either  too  much  confined,  or  are  urged  to  diarrhoea;  and  if  au 
attempt  be  made  to  remove  the  former  condition  by  purgative 
remedies,  the  latter  is  certain  to  follow,  by  which  every  local 
symptom  is  severely  augmented ;  and  thus  the  patient  suffers  al- 
most alike,  from  either  of  these  conditions. 

The  urine,  for  the  most  part,  is  sparing,  high-coloured,  strong- 
smelling,  and  throws  down,  when  at  rest,  a  large  deposit — or  it 
is  pale,  abundant,  and  free  from  deposition ;  but  when  this  occurs, 
we  have  reason  to  suspect  the  disease  is  complicated  with  a  cer- 
tain form  of  neuralgia.  The  urine  is  generally  discharged  witli 
some  difficulty,  and  even  pain  is  felt  along  the  course  of  thoi 
urethra.  Occasionally,  the  urine  is  suppressed  or  retained  for 
many  hours  together,  and  is  then  voided  with  considerable  suffer- 
ing. 

Local  Symptoms. — Sometimes  the  patient  represents  the  parf.s 
as  being  a  little  swelled :  but  this  we  believe  is  always  transient. 
Walking,  riding,  or  indeed  any  kind  of  exertion,  is  sure  to  be 
accompanied  or  followed  by  severe  lancinating  pains  within  the 
pelvic  cavity,  especially  from  near,  or  in  the  course  of,  the  ure- 
thra, to  about  the  centre  of  the  sacrum ;  and  when  the  severity 
of  the  pain  has  abated,  it  subsides  into  a  permanent  dull  pain  in 
the  same  direction,  but  more  diffused. 


292  IRRITABLE   UTERUS. 

More  or  less  leucorrhcea  pretty  certainly  attends ;  the  colour  of 
which  varies  almost  in  proportion  to  the  degree  of  suffering ;  when 
this  is  not  very  intense,  it  is  thin  and  nearly  transparent,  pretty 
abundant,  and  without  odour;  while,  on  the  contrary,  when  the 
pain  is  very  severe  and  permanent,  the  discharge  is  thick,  puru- 
lent, and  is,  if  strict  regard  be  not  paid  to  cleanliness,  oifensive. 

The  uterus  is  almost  always  lower  in  the  vagina  than  natural, 
and  sometimes,  indeed  not  unfrequently,  it  is  found  prolapsed.1 
There  is  considerable  heat  in  the  vagina,  and  always,  so  far  as 
we  have  observed,  a  more  than  ordinary  degree  of  sensibility  in 
its  parietes.  In  this  we  differ  from  the  respectable  authority  of 
Dr.  Gooch,  who  says  this  tenderness  is  confined  to  the  neck  of 
the  uterus.8  The  neck  is  almost  always  a  little  shortened,  en- 
larged, and  exquisitely  sensible  to  the  touch,  and  the  os  tincse  is 
rather  more  closed  than  natural.  The  pain  which  attends  this 
complaint  is  always  increased  by  an  erect  position,  and  it  as  cer- 
tainly abates  by  a  recumbent  one.  Pain  is  usually  felt  immedi- 
ately behind  the  mons  veneris  and  brim  of  the  pelvis,  especially 
its  anterior  portion. 

The  sensibility  of  the  neck  of  the  uterus  is  at  times  so  exqui- 
sitely great,  that  the  woman  shrieks  if  it  be  rather  rudely  touched ; 
nor  does  this  pain  cease,  even  for  a  very  long  time  after  it  has 
been  excited,  especially  at  the  lower  part  of  the  sacrum.  Dr. 
Gooch  tells  us,  that  in  a  patient  of  his,  it  would  remain  for  many 
hours,  with  great  severity.  Indeed,  this  tenderness  is  so  great  and 
so  constant,  in  many  instances,  that  great  suffering  is  experienced 
if  the  patient  incautiously  sit  down  too  suddenly,  and  particularly 
if  upon  a  hard,  unresisting  seat;  and  the  privileges  of  matrimony 
cannot  be  consummated  without  much  suffering. 

Besides  these  local  inconveniences,  there  is  a  symptom  which 
is  almost  constantly  present,  and  which  seems,  according  to  our 
experience,  in  an  especial  manner  to  characterize  the  "irritable 
uterus,"  but  which  is  not  noticed  by  either  Dr.  Gooch,3  or  Dr. 
Addison,4  or  M.  Genest : 5  this  is  a  pulsating,  throbbing,  or  flut- 
tering sensation  within  the  vagina  or  pelvic  cavity.  So  far,  we 
have  never  known  this  symptom  wanting  in  this  affection,  though 
it  differs  very  much  in  degree.  In  some  few  instances  we  have 
known  it  to  interrupt  sleep ;  but  this  is  not  the  usual  state  of  this 
symptom,  though  it  is  represented  to  be  very  disagreeable  al- 
ways. This  sensation,  however,  is  not  constant;  it  often  suffers 

*  By  prolapsus,  we  would  wish  to  be  understood,  such  a  descent  of  the  uterus 
as  causes  it  to  rest  upon  the  internal  face  of  the  perineum. 

"  Dr.  Gooch  says,  "The  finger  can  be  introduced  into  the  vagina,  and  be  pressed 
against  its  sides,  without  producing  uneasiness,"  p.  312. 

*  Opera  Citata. 

1  "  Observations  upon  Diseases  of  Females." 

*  Recherches  sur  1'Hysteralgie  ou  Neuralgic  Uterine,  et  son  Traitement    Ga- 
zette Med.  de  Paris,  Sept.  1830. 


IRRITABLE    UTERUS.  293 

abatement,  and  occasionally  is  absent — but  when  present,  it 
marks  the  irritable  uterus  in  an  especial  manner. 

Dr.  Gooch  and  Dr.  Addison,  in  their  descriptions  of  the  "ir- 
ritable uterus,"  have  added  many  symptoms  that  do  not  belong 
to  this  affection  when  simple  and  uncomplicated.  To  be  con- 
vinced of  this,  it  will  only  be  necessary  to  compare  the  sympr 
toms  we  have  detailed  above,  with  those  enumerated  by  these 
gentlemen.  Dr.  A.  lays  down  the  following  marks,  as  belonging 
to,  or  produced  by,  "uterine  irritation."  He  declares  the  most 
frequent  symptoms  of  this  condition  to  be — 

"Irregular  menstruation,  the  discharge  being  preceded  or  ac- 
companied by  pain  in  the  back,  loins,  thighs,  or  in  the  region  of 
the  uterus  itself,  attended  with  forcing  or  bearing  down ;  the  dis- 
charge being  in  excess,  either  in  point  of  mere  quantity,  in  con- 
tinuance, or  in  recurrence ;  tenderness  of  the  womb  itself,  upon 
pressure  made  either  externally  or  per  vaginam ;  a  tenderness  so 
great  as  to  interfere  with  the  privileges  of  matrimony,  and,  lastly, 
leucorrhosa.  The  most  frequent  symptoms,  however,  are,  un- 
questionably, painful  menstruation  and  leucorrhoeal  discharge. 
Such  are  the  few  plain,  simple  indications  of  a  state  of  the  ute- 
rus which  is  repeatedly  overlooked,  though  productive  of  the 
most  serious  disturbance,  both  of  the  general  health,  and  of  par- 
ticular organs ;  disturbance  which,  when  once  produced,  stamps 
a  character  upon  the  general  and  local  ailments  of  the  sufferer, 
strongly  indicative,  to  the  experienced  man,  of  uterine  irritation : 
a  character  which  confirms  us  in  the  belief  that  it  is  from  such 
irritation  that  the  evil  originates,  and  that  it  is  to  correct  the 
condition  of  the  uterine  system  that  his  chief  attention  is  to  be 
directed,"  p.  12. 

In  addition  to  these  symptoms,  Dr.  A.  enumerates  a  long  train 
of  nervous  symptoms  as  belonging  to  this  affection — in  a  word, 
he  describes  a  well  confirmed  hysteria.  Indeed,  the  description 
given  by  Dr.  A.  and  that  given  by  us,  do  not  agree  in  a  sufficient 
number  of  important  points,  to  induce  us  to  believe  we  are  de- 
scribing one  and  the  same  disease. 

First.  The  greater  part  of  the  symptoms  enumerated  by  Dr 
A.  is  descriptive  of  simple  dysmenorrhoea. 

Second.  He  makes  the  cause  of  "uterine  irritation"  consist 
in  "irregular  menstruation;"1  whereas,  we  are  of  opinion  that 

1  He  says  that  "  menstruation  continues  as  usual,  or  perhaps  a  little  more 
abundant;  but  generally  it  is  less,  and  sometimes  suppressed."  From  this  we 
should  be  led  to  conclude  that  dysmenorrhoea,  or  even  irregularity,  in  his  estima- 
tion, are  the  causes  of  this  complaint.  We  are  every  way  certain  that  we  have 
seen  the  "  irritable  uterus  "  unaccompanied  by  dysmenorrheea ;  and  we  are  equally 
certain  that  we  have  seen  the  latter  many  times  extremely  severe,  without  the 
former — these  conditions  appear  to  be  rather  the  consequences  than  the  cause  of 
the  "  irritable  uterus"  in  many  instances,  while,  in  many  others,  they  are  unat- 
tended by  them. 


294  IRRITABLE    UTERUS. 

the  aberrations  of  the  menstrual  discharge,  if  there  be  any,  are 
owing  to  the  inflamed  or  irritable  condition  of  the  neck  of  the 
uterus. 

Third.  The  initial  symptoms  of  the  "irritable  uterus  "  are  not 
those  of  nervous  mobility,  though  these  symptoms  are  almost  sure 
to  follow,  if  the  disease  persist  for  a  considerable  time. 

Fourth.  The  symptoms  laid  down  by  Dr.  A.  are  virtually  the 
same  as  those  to  which  the  inflamed  spine  gives  rise,  and  which 
affection,  agreeably  to  Mr.  Tate,  produces  the  hysterical  pheno- 
mena. These  symptoms,  however,  do  not  necessarily  belong  to 
the  "irritable  uterus,"  but  may  be  looked  upon  as  purely  ner- 
vous, and  arise  out  of  a  morbid  condition  of  some  other  part,  or 
may  be  the  result  of  an  ''irritable  uterus."  Dr.  A.  thus  cautions 
upon  this  point: — 

"Whenever  a  female  complains  of  a  pain  under  the  left  breast, 
•with  or  without  palpitation  or  pulsation  of  the  heart ;  of  pain  in 
the  right  hypochondrium ;  in  the  situation  of  the  left  or  right 
colon :  or  acute  pain  generally  over  the  whole  belly,  or  in  the 
region  of  the  bladder  or  kidneys — always  be  upon  your  guard; 
and  if,  upon  inquiry,  you  find  few  or  many  of  the  constitutional 
symptoms  I  have  described,  together  with  uterine  irritation,  as 
shown  by  pain  in  the  pelvis,  in  the  loins,  or  in  the  thighs,  before 
or  during  jthe  flow  of  the  catamenia ;  by  too  frequent  or  too  pro- 
fuse menstruation;  or  by  leucorrhoeal  discharge:  I  say,  when 
you  find  such  an  assemblage  of  symptoms  and  circumstances, 
your  suspicions  will  amount  to  a  high  degree  of  probability  that 
the  complaint  is  not  of  an  inflammatory  nature,"  p.  31. 

Now  these  very  symptoms,  we  must  repeat,  Mr.  Tate  declares 
to  belong  to  the  inflamed  spine.  We  must,  therefore,  say,  that 
when  these  symptoms  prevail,  that  neuralgia  is  either  combined 
with,  or  is  existing  independently  of,  the  "irritable  uterus;"  for 
we  are  of  opinion,  that  the  "irritable  uterus"  may  exist  in  its 
gravest  form  in  a  state  of  combination  with  neuralgia,  or  it  may 
be  present  without  this  complication,  and  exist  independently. 
We  think  this  opinion  is  abundantly  confirmed  by  the  symptoms 
enumerated  by  Dr.  A.  as  constituting,  or  as  arising  from,  "ute- 
rine irritation;"  but  which,  as  we  have  just  said,  Mr.  Tate 
claims  for  inflamed  spine.  Such  as  a  pain  seated  under  the 
left  breast,  or  under  the  margin  of  the  ribs  of  the  same  side ; 
or  pain  under  the  margin  of  the  ribs  of  the  right  side ;  pain  in 
the  course  of  the  ascending  and  descending  colon ;  pain  affect- 
ing the  whole  abdomen ;  pain  in  the  region  of  the  stomach ; 
and,  lastly,  pain  in  the  region  of  the  kidneys ;  sometimes  extend- 
ing down  the  course  of  the  uterus  to  the  bladder,  p.  22.  Now, 
in  our  opinion,  the  first  five  of  the  symptoms  do  not  belong  to 
the  pure,  or  idiopathic,  "irritable  uterus."  First,  because  we 
have  known  them  to  be  absent  in  several  instances  of  exquisite- 


IKEITABLE   UTERUS.  295 

ly  formed  "irritable  uterus;"  2dly,  because  they  are  constantly 
present  in  hysteria,  where  the  uterus  may  be  in  a  perfectly  healthy 
state — for  we  have  witnessed  them  in  women  who  bear  healthy 
children ;  but  we  have  never  known  conception  to  take  place  in 
women  who  labour  under  "irritable  uterus."  And  the  last  enu- 
merated sign  belongs  more  properly  to  the  carcinomatous  than 
to  the  "irritable  uterus." 

Fifth.  Dr.  A.  makes  very  young  females  liable  to  the  disease 
which  he  describes;  now  we  have  seen  the  "irritable  uterus" 
only  in  women  who  had  arrived  near,  or  had  passed,  the  middle 
period  of  life.1 

Diagnosis. — The  "irritable  uterus  "  may  be  distinguished  from 
a  neuralgic  condition  of  this  part  by  the  following  important  par- 
ticulars. 1st,  In  neuralgia  of  the  uterus  there  is  an  entire  absence, 
at  least  as  far  as  we  have  observed,  of  the  general,  or  what  we 
have  termed  the  constitutional  symptoms,  especially  the  evening 
febrile  movement.  2d,  There  is  seldom,  (nor  is  there  ever,  neces- 
sarily,) a  vaginal  or  leucorrhoeal  discharge;  if  it  be  present,  it 
may  have  been  habitual,  and  have  existed  before  the  neuralgic 
attack.  3d,  There  is  no  preternatural  heat  in  the  vagina.  4th, 
Nor  is  the  uterus  so  sensible  to  the  touch,  unless  it  be  examined 
during  the  painful  continuance  of  the  paroxysm,  and  then,  per- 
haps, it  is  even  more  exquisitely  sensible  than  it  is  in  the  pure 
"irritable  uterus ;"  besides,  in  neuralgia,  the  pain  is  less  constant, 
but  is  more  violent  during  the  paroxysms,  and  these  pretty  con- 
stantly observe  periodicity,  but  which  the  "irritable  uterus"  is 
free  from.  5th,  In  neuralgia,  a  paroxysm  may  be  suddenly  in- 
duced by  passions  or  emotions  of  the  mind,  which  is  never  the 
case  in  the  "irritable  uterus,"  though  the  latter  is  susceptible  of 
great  and  occasional  augmentation  of  pain,  through  the  medium 
of  the  circulation,  by  errors  in  diet,  or  improper  exposure. 

The  "irritable  uterus  "  is,  however,  more  frequently  confound- 
ed with  prolapsus  uteri  than  with  any  other  complaint,  as  the 
local  symptoms  of  the  latter  are  a  miniature  representation  of  the 
former.  And  as  the  womb  is  almost  sure  to  descend  more  or 
less  in  the  "  irritable  uterus,"  this  precipitation  has  been  supposed 

1  Since  the  above  was  written,  I  have  been  consulted  by  letter,  in  the  case  of  a 
young  lady,  only  eighteen,  who,  I  have  not  the  smallest  doubt,  is  labouring  under 
"  irritable  uterus,"  and  forms  an  exception  to  the  general  rule  of  the  period  of  life 
at  which  this  disease  may  show  itself.  All  the  symptoms  that  mark  this  disease 
are  present,  even  to  the  prolapsed  state  of  the  uterus.  This  is  a  case  of  great  in- 
terest, as  it  occurs  in  a  young  person  who,  in  other  respects,  enjoys  a  fair  propor- 
tion of  health;  but  which  will,  and  must  very  soon,  be  destroyed,  if  this  terrible 
affection  be  not  speedily  removed.  There  is,  in  this  young  lady,  a  strong  scrofu- 
lous tendency,  with  some  development. 

We  have  recommended  absolute  rest;  a  milk  and  vegetable  diet;  the  rhubarb 
pill;  occasionally,  leeching  or  cupping;  the  iodine,  and  injections  of  the  solution 
of  the  nitrate  of  silver,  on  the  faith  of  its  influence  upon  certain  inflamed  surfaces 
in  other  parts  of  the  body. 


296  IRRITABLE   UTERUS. 

to  be  the  cause  of  all  the  inconveniences  experienced;  and  hence, 
the  frequent  failures  of  the  pessary  when  it  has  been  applied  for 
the  relief  of  the  prolapsus.  Nay,  sometimes  serious  and  perma- 
nent injury  has  been  done  by  this  instrument  in  these  cases,  with- 
out the  practitioner  being  exactly  aware  why  mischief  should  be 
caused  by  a  machine  that  had  been  so  often  successful  in  cases 
so  apparently  alike. 

Consequently,  it  is  a  matter  of  much  moment,  that  the  two 
affections  should  not  be  confounded;  we  would,  therefore,  sug- 
gest the  observance  of  the  following  precautions,  when  an  exami- 
nation is  about  to  be  made  per  vaginam,  for  prolapsus  uteri. 
First.  Let  the  patient  be  placed  upon  her  back  with  the  knees 
drawn  up.  Second.  Let  the  parts  be  well  lubricated,  that  no  pain 
may  be  excited  by  the  introduction  of  the  finger,  lest  a  wrong 
conclusion  be  drawn  from  the  complainings  of  the  patient.  Third. 
After  the  finger  has  possession  of  the  vagina,  a  gentle  search 
should  be  made  for  the  neck  of  the  uterus,  and  when  found,  the 
patient's  attention  should  be  solicited  to  the  degree  of  sensation 
produced  by  touching  it ;  the  portion  of  the  body  of  the  uterus 
immediately  above  the  neck,  and  the  sides  of  the  vagina — inquire 
if  there  be  any  extraordinary  sensibility  in  either  of  these  parts ; 
and  if  there  be,  in  which  of  the  parts  it  resides ;  and  if  either  of 
these  parts  be  morbidly  tender,  the  pessary  must  not  be  intro- 
duced, until  this  has  been  abated  by  suitable  means.  In  this  case 
the  patient  will  be  labouring  under  "irritable  uterus,"  and  not  a 
simple  prolapsus.  Besides,  in  the  "irritable  uterus."  the  pro- 
lapsus is  not  always  permanent — but  sometimes  only  so  in  the 
erect  position  of  the  body,  as  in  standing. 

The  "irritable  uterus"  has  also  been  confounded  with  carci- 
noma of  this  organ,  when  it  has  been  about  to  throw  off  its  indo- 
lent condition,  and  to  commence  the  ulcerative  process.  But  the 
"irritable  uterus  "  is  easily  distinguished  from  the  carcinoma,  by 
the  neck  of  the  uterus,  in  the  latter,  still  retaining  the  original 
marks  of  carcinoma;  as  a  thickening  of  the  whole  of  its  substance; 
by  its  having  a  cartilaginous  feel ;  by  its  being  shorter ;  and  the 
os  tincae  being  more  open  than  natural;  by  tumours  still  occupy- 
ing the  neck  and  pelvic  portion  of  the  body  of  the  uterus ;  by  a 
pretty  abundant  and  sometimes  constant  discharge  of  a  serous 
fluid,  which  may  be  occasionally  tinged  with  blood,  and  the 
almost  entire  filling  up  of  the  vagina  by  the  increased  size  of  the 
uterus. 

The  "irritable  uterus"  has  also  been  confounded  with  dys- 
menorrhosa,  but  from  this  functional  derangement  of  the  uterus 
it  is  easily  distinguished.  First.  In  dysmenorrhoea  pain  is  only 
felt  during  the  menstrual  action ;  whereas,  in  the  other,  the  suf- 
fering is  more  or  less  constant,  though  subject  to  occasional  ag- 
gravation, and  this  of  a  severe  kind,  at  other  than  the  catamenial 


IRRITABLE   UTERUS.  297 

periods.  Secondly.  The  "irritable  uterus"  is  not  necessarily  at- 
tended by  dysmenorrhcea,  nor  is  dysmenorrhoea  usually  attended 
by  this  irritable  condition  of  the  uterus;  for  we  have  seen  very 
many  instances  to  the  contrary. 

Pathology. — We  have  already  declared  our  belief  that  this,  dis- 
ease consists  in  a  chronic  or  sub-acute  inflammation  of  perhaps 
all  the  tissues  that  compose  the  neck  of  the  uterus.  The  patho- 
logical condition  of  the  womb,  in  this  complaint,  has,  however, 
never  been  ascertained,  by  post  mortem  examination,  as  it  very 
seldom,  or  perhaps  never,  of  itself,  destroys  the  patient.  It 
were  much  to  be  desired,  that  an  examination  be  made,  should 
opportunity  present — as  we  are  of  opinion,  that  more  derange- 
ment of  structure  would  be  found  in  some  cases,  than  appears 
to  be  allowed  to  exist  by  either  Dr.  Gooch  or  M.  Genest,  for  we 
have  met  with  several  cases  in  which  the  size  and  form  of  the 
neck  of  the  uterus  was  much  altered  from  its  natural  condition. 
Indeed  the  admission  of  Dr.  G.  and  M.  Genest  would  seem  to 
declare  the  same  thing.  Dr.  G.  admits  that  "the  neck  of  the 
uterus  is  slightly  swollen,"  (p.  312,)  though  he  denies  a  change 
in  its  structure.  M.  Genest  declares  the  same  thing;  indeed, 
the  latter  seems  but  to  have  copied  Dr.  G..  in  his  account  of  this 
disease.  It  is  true,  he  has  seen  the  disease,  and  appears  to  have 
been  attentive  to  its  phenomena;  yet  we  would  be  rather  dis- 
posed to  question  his  accuracy,  as  he  mentions  that  this  disease 
continued  during  the  whole  of  a  pregnancy  that  terminated 
happily.  Now,  as  far  as  we  have  had  opportunities  of  noticing 
this  disease,  (which  have  been  many,)  we  have  never  known  a 
single  instance  of  impregnation  in  a  patient  labouring  under  the 
"irritable  uterus." 

We  admit  that,  in  an  unmixed  or  idiopathic  neuralgia  of  the 
uterus,  very  little,  if  any,  derangement  of  structure  takes  place ; 
from  which  circumstance,  we  are  disposed  to  believe,  that  when 
this  undisturbed  condition  of  the  womb  is  met  with,  it  betrays 
the  neuralgic  form  of  this  disease. 

Dr.  Gooch  will  not  admit  the  uterus  to  be  in  a  state  of  chro- 
nic inflammation.  He  saya  that  chronic  inflammation,  like  the 
acute,  is  always  "a  disorganizing  process;"  but  if  we  are  not 
very  much  in  error,  a  chronic  inflammation  may  exist  for  an 
almost  indefinite  period,  in  some  instances,  without  any  very 
manifest  derangement  of  a  part ;  and  that  there  is  some  derange- 
ment in  the  "irritable  uterus,"  we  are,  from  many  observations, 
very  certain — besides,  there  are  present  in  this  affection  all  the 
common  characters  of  inflammation — as  heat,  swelling,  and  pain; 
but  whether  there  be  unusual  redness  also,  we  are  not  prepared 
to  determine. 

We  are,  therefore,  disposed  to  believe  that  the  conclusion  of 
Dr.  Gooch  is  rather  hasty;  for,  indeed,  his  attempt  to  support  his 
opinion  is  rather  by  analogies  than  by  pathological  observation. 


IRRITABLE   UTERUS. 

|U«  f 

He  says,  "The  disease  which  I  am  describing  resembles  a  state 
which  other  organs  are  subject  to,  and  which,  in  them,  is  deno- 
minated irritation.  Surgeons  describe  what  they  call  an  irritable 
tumour  in  the  breast.  It  is  exquisitely  tender;  an  ungentle  exa- 
mination of  the  part  leaves  pain  for  hours;  it  is  always  in  pain; 
but  this  is  greatly  increased  every  month,  immediately  before  the 
menstrual  period.  Although  apprehensions  are  entertained  of 
cancer,  it  never  terminates  in  disease  of  structure."  "Mr.  Bro- 
die  describes  a  similar  state  in  the  joints."  It  chiefly  occurs 
amongst  hysterical  females;  it  is  attended  by  pain;  at  first  with- 
out any  tumefaction ;  but  the  pain  increases,  and  is  attended  with 
a  puffy,  diffused,  but  trifling  swelling;  the  part  is  exceedingly 
tender ;  this  assemblage  of  symptoms  lasting  a  long  time,  and 
being  often  little  relieved  by  remedies,  occasions  great  anxiety, 
but  "there  never  arise  any  ultimate  bad  consequences."  "The 
disease,"  says  Mr.  Brodie,  "appears  to  depend  on  a  morbid  con- 
dition of  the  nerves,  and  may  be  regarded  as  a  local  hysteric 
affection."  "These  painful  states  of  the  breast,  and  of  the  joints, 
appear  to  be  similar  to  that  which  I  have  been  describing  in  the 
uterus ;  similar  in  the  kinds  of  constitutions  which  they  attack ; 
similar  in  pain;  in  exquisite  tenderness;  in  resemblance  to  the 
commencement  of  organic  disease ;  and  in  proving  ultimately  to 
be  only  diseases  of  function,"  p.  318. 

Now,  we  would  ask,  if  the  condition  of  the  parts  here  described, 
and  that  of  the  portion  of  the  womb  implicated  in  the  disease  we 
are  treating  of,  were  identical,  would  it  prove,  that  the  symptoms 
to  which  they  give  rise  do  not  depend  upon  a  modified  inflamma- 
tion? Does  the  attempt  to  illustrate  the  condition  of  a  part  in- 
volved in  disease,  by  adducing  the  inexplicable  phenomena  pre- 
sented by  diseases  of  other  parts,  (however  strong  their  analogy 
may  be,)  throw  any  light  upon  its  pathology  ?  Is  not  the  patho- 
logy of  "  the  irritable  breast,"  or,  "certain  affections  of  the  joints," 
as  entirely  unascertained  as  the  situation  of  the  structure  involved 
in  the  " irritable  uterus?"  Does  any  definite  pathological  condi- 
tion of  a  part  present  itself  to  the  mind,  by  saying  that  the  phe- 
nomena of  the  diseases  offered  as  illustrations  depend  "  upon  a 
morbid  condition  of  the  nerves,  and  may  be  regarded  as  a  local 
hysteric  affection?"  or,  in  other  words,  is  our  knowledge  of  the 
pathology  of  the  "irritable  uterus"  any  way  advanced  by  de- 
claring it  is  the  same  as  in  a  "local  hysteric  affection?"  Who 
has  demonstrated  the  condition  of  either  the  brain  or  the  nerves, 
which  give  rise'to  the  phenomena  of  hysteria;  of  the  glands  of 
the  mamma  in  "the  irritable  tumour  of  the  breast,"  or  of  the 
joints,  in  the  disease  of  these  parts,  as  described  by  Mr.  Brodie  ? 
Has  it  been  proved,  that  the  affection  of  a  part  called  inflamma- 
tion, (either  acute  or  chronic,)  has  no  agency  in  the  production 
of  the  symptoms  which  characterize  the  several  diseases  just 
named?  Certainly  it  has  not. 


IRRITABLE     UTERUS.  299 

Does  Dr.  Gooch's  denial,  that  the  "irritable  uterus"  depends 
upon  a  chronic  inflammation  of  the  neck,  and  perhaps  a  portion 
of  the  body  of  the  womb,  derive  any  support  from  Dr.  Anderson 
declaring  the  same  thing?  We  think  not. 

In  fact,  whilst  Dr.  Gooch  denies  the  presence  of  inflammation, 
he  at  the  same  time  furnishes  us,  in  the  history  of  his  cases,  with 
sufficient  evidence  that  this  condition  of  the  parts  concerned 
really  exists.  Thus,  in  relating  the  history  of  the  disease  in 
question,  one  of  his  patients,  he  says, — 

"  In  the  lowest  part  of  the  abdomen,  or  a  little  lower  even  than 
that  internally,  she  first  felt  a  sense  of  heat ;  to  this  was  speedily 
added  a  sense  of  throbbing,  then  a  sense  of  distention,  as  if  there 
was  a  tumour  within,  which  gradually  expanded  till  it  felt  ready 
to  burst:  then  began  spasms;  these  she  described  as  shooting,  or 
electric  shocks,  darting  from  the  tumour  up  into  the  abdomen ; 
they  recurred  every  five  or  ten  minutes,  making  her  start  with 
such  violence  as  to  shake  the  bed.  I  have  been  in  the  adjoining 
room  when  she  has  been  in  this  state,  and  have  perceived  the 
shock;  between  the  spasms  she  felt  what  she  called  a  convulsive 
pain.  Nothing  relieved  these  spasms  but  a  small  local  bleeding  ; 
she  has  used  fomentations,  simple  and  medicated,  for  many  hours, 
hip  baths,  opium  in  draughts,  and  in  injections,  without  relief; 
but  as  soon  as  four  or  six  leeches  were  applied,  and  had  drawn 
blood,  the  spasms,  distention,  throbbing,  and  heat,  speedily  sub- 
sided, leaving  a  dull  permanent  uneasiness.  The  uterus  was  so 
tender,  that  the  examination  of  it  was  torture,  and  left  severe 
suffering  for  hours,"1  p.  335. 

Need  better  proof  be  given  of  the  inflammatory  nature  of  the 
irritable  uterus  than  the  treatment  of  this  case  ?  Certain  sensa- 
tions of  spasms  accompanied  this  complaint ;  the  sensations  are 
described  as  consisting  of  local  heat,  throbbing,  and  expansion,  to 
a  feeling  like  bursting;  the  spasms  as  shooting  or  electric  shocks, 
darting  from  the  uterus  up  into  the  abdomen,  which  we  are  in- 
formed neither  opium  nor  other  means  would  appease,  though 
persisted  in  for  hours,  yet  were  "instantly  relieved  by  four  or 
six  leeches!" 

Causes. — The  remote  causes  of  this  very  tedious  and  painful 
affection  are  involved  in  great  obscurity — indeed  it  may  be  ques- 
tioned whether  any  satisfactory  remote  or  predisposing  cause 
has  ever  been  assigned,  though  we  are  in  possession  of  a  number 
of  the  exciting.  These  consist  chiefly  in  severe  fatigue,  or  other 
bodily  exertion,  as  it  almost  always  shows  itself,  after  this  has 
taken  place,  where  predisposition  has  existed.  Dr.  Gooch  says — 

1  We  have  never  met  with  such  an  exquisite  degree  of  sensibility  in  the  genuine 
•uncomplicated  irritable  uterus,  as  is  here  spoken  of;  where  this  has  existed,  to  the 
extent  described  by  Dr.  Gooch,  we  have  always  had  reason  to  suspect  neuralgia 
was  added. 


300  IRRITABLE    UTERUS. 

"In  one  patient  it  came  on  after  an  enormous  walk  during  a 
menstrual  period;  in  another,  it  was  occasioned  by  the  patient's 
going  a  shooting  with  her  husband,  not  many  days  after  an  abor- 
tion ;  in  a  third,  it  came  on  after  standing  for  several  hours  many 
successive  nights  at  concerts  and  parties ;  in  a  fourth,  it  originated 
in  a  journey  in  a  rough  carriage  over  the  paved  roads  of  France ; 
in  a  fifth,  it  was  attributed  either  to  cold  or  an  astringent  lotion, 
by  which  a  profuse  lochia  was  suddenly  stopped,  followed  by 
intense  pain  in  the  uterus  ;  in  a  sixth,  it  occurred  soon  after,  and 
apparently  in  consequence  of  matrimony,"  p.  314. 

It  is  evident  that  the  causes  here  enumerated  were  only  ex- 
citing causes ;  in  none  do  we  discover  the  predisposing,  if  we  ex- 
cept the  instance  of  abortion.  It  is  more  than  probable  that  this 
effort  of  the  uterus  may  be  one  of  the  common  predisposing  causes 
of  the  "  irritable  uterus;"  we  at  least  can  say,  that  three  of  the 
severest  cases  we  have  met  with  were  preceded  by  abortion. 
But,  if  abortion  be  admitted  as  the  predisponent,  it  must  also 
be  granted  that  there  may  be  many  other  causes,  as  we  witness 
the  "irritable  uterus"  in  the  unmarried,  and  in  the  widow  fe- 
male, where  abortion  has  had  no  agency. 

Dr.  Gooch  says,  his  "  patients  had  previously  manifested  signs 
of  predisposition  to  it ;  they  were  all  sensitive  in  body  and  mind : 
many  of  them  had  been  previously  subject  to  the  ordinary  form 
of  painful  menstruation."  He  then  adds,  with  a  view,  we  pre- 
sume, of  conveying  some  idea  of  the  pathological  condition  of  the 
uterus,  that  "the  disease  seemed  to  consist  in  a  state  of  the 
uterus  similar  to  that  of  painful  menstruation,  only  permanent 
instead  of  occasional,"  p.  315. 

Upon  these  observations,  we  beg  leave  to  offer  a  few  remarks, 
that  our  experience  in  the  affection  under  consideration  has  sug- 
gested. First,  it  by  no  means  accords  with  our  observations, 
that  those  who  are  "sensitive  in  body  and  mind,"  are  more  ob- 
noxious to  the  "irritable  uterus  "  than  those  of  an  opposite  tem- 
perament— for  we  have  seen  this  disease  in  its  most  aggravated 
form  in  the  hale  and  robust,  and  especially  such  as  were  of  the 
sanguine  temperament.  Secondly,  That  no  analogy  exists  be- 
tween that  state  of  the  uterus  which  gives  rise  to  dysmenorrhoea, 
and  that  in  which  consists  the  "irritable  uterus."  For  dysme- 
norrhoea is  owing  to  a  certain  pathological  condition  of  the  in- 
ternal and  secreting  surface  of  the  uterine  cavity;  whereas,  in 
the  "irritable  uterus,"  some  change  has  been  produced  in  the 
parenchyma  composing  the  neck  of  this  organ,  and  to  which  the 
disease  is  confined,  agreeably  to  Dr.  Gooch's  own  showing. 
Thirdly,  As  we  do  not  know  in  what  manner  the  inner  lining  of 
the  body  and  fundus  of  the  uterus  is  affected,  to  produce  painful 
menstruation,  so  we  cannot  be  enlightened  in  regard  to  the  pa- 
thological condition  of  the  neck,  while  labouring  under  the  con- 


IRRITABLE    UTERUS.  301 

dition  vie  are  treating  of.  Fourthly,  In  dysmenorrhrea,  the  pain 
that  accompanies  the  secretion  of  the  menstrual  blood,  is  not 
caused  by  any  particular  condition  of  the  secreting  organ,  ab- 
stractly considered ;  but  to  the  changes  wrought  upon  this 
fluid  itself  during  its  elimination,  causing  it  to  remain  within  the 
uterine  cavity,  until  it  becomes,  to  all  intents  and  purposes,  a 
foreign  body,  and  requiring  the  aid  of  uterine  contraction  to  expel 
it — hence  the  pain  of  dysmenorrhoea,  and,  consequently,  between 
it,  and  that  attendant  upon  the  "irritable  uterus,"  there  is  not 
the  slightest  resemblance  in  either  kind  or  cause.  Fifthly,  Were 
there  the  strongest  resemblance  between  the  pathological  condi- 
tion of  the  internal  surface  of  the  uterine  cavity,  and  that  of  the 
neck  of  the  uterus,  in  the  two  affections  under  consideration,  we 
should  not  profit  from  the  analogy,  as  Dr.  G.  has  not  pointed 
out  the  condition  of  the  former,  that  we  might  benefit  from  its 
resemblance  to  the  latter. 

Dr.  Gooch  insists  that  the  "irritable  uterus"  is  "a  disease  of 
function,  and  not  of  structure,"  p.  316.  We  would  ask  of  what 
function  ?  For  Dr.  G.  admits  that  the  menses  continue  to  be  dis- 
charged, though  not  in  the  most  healthy  manner ;  but  we  have 
endeavoured  to  show  that  there  is  no  necessary  connexion  be- 
tween the  discharge  and  the  disease  in  question — for  we  have- 
seen  them,  as  we  have  observed  before,  altogether  independent  of 
each  other.  And,  if  it  be  not  the  catamenial  function  to  which 
he  alludes,  we  are  altogether  at  a  loss  to  what  other  to  assign  it. 

Treatment. — Would  it  were  in  our  power  to  say  that  the 
treatment  of  the  "irritable  uterus"  were  as  well  understood,  and 
as  void  of  difficulty  and  uncertainty,  as  its  obstinacy  and  seve- 
rity render  it  desirable ;  for  were  we  candid,  we  must  honestly 
confess  that  the  contrary  of  this  is  nearer  the  truth.  This  diffi- 
culty, however,  does  not  arise  so  much  from  the  indomitable  na- 
ture of  the  disease,  as  from  the  length  of  time  required  to  over- 
come it,  and  the  privations  to  which  the  woman  must  submit  who 
looks  forward  to  its  cure.  Patience  becomes  exhausted,  and 
confidence  in  the  efficacy  of  remedies  is  too  quickly  destroyed ; 
for  relief  is  not  only  almost  ahvays  tardy,  but  is  too  often  un- 
certain; especially  with  patients  whose  circumstances  and  avo- 
cations will  not  permit  them  to  fulfil  any  plan,  however  judi- 
ciously laid  down,  or  however  important  its  adoption  may  be  to 
their  welfare. 

We  have  just  declared  that  relief  in  this  disease  is  almost  al- 
ways tardy;  for  however  judiciously  remedies  may  be  advised, 
or  however  faithfully  they  may  be  applied,  they  are  far  from 
being  uniformly  speedy  in  their  effects:  in  this  opinion  we  do  not 
stand  alone ;  for  it  is  the  declaration  of  the  several  authorities 
we  have  quoted  above,  and  but  too  certainly  confirmed  by  our 
own  experience ;  months,  nay  years,  are  sometimes  required  to 


302  IRRITABLE    UTERUS. 

accomplish  a  cure ;  and  if  this  be  effected  even  after  a  very  long 
trial  of  means,  the  woman  may  felicitate  herself  that  she  has 
been  able  to  procure  health,  even  at  so  great  a  price. 

In  no  disease  does  recovery  so  much  depend  upon  the  conduct 
of  the  patient  herself,  as  in  the  "irritable  uterus."  The  patient 
.must  make  up  her  mind  to  a  long  and  irksome  confinement  to 
bed;  she  must  consent  to,  perhaps,  the  frequent  use  of  external 
applications  and  internal  remedies,  and  submit  to  a  system  of 
diet  or  abstinence  that  will  not  bear  infraction  with  impunity,  if 
she  expect  to  recover  from  this  painful,  wayward,  and  perplex- 
ing affection.  All  this  should  be  fairly  and  candidly  stated,  and 
the  patient's  mind  should  be  duly  impressed  with  the  absolute 
necessity  of  perseverance,  and  of  the  penalties  that  will  await 
neglect,  or  that  will  follow  infringement. 

On  the  part  of  the  practitioner,  much  caution,  as  well  as  pru- 
dence is  required,  that  no  ill-founded  hopes  may  be  raised,  or 
that  the  patient  may  not  be  unnecessarily  sunk  to  despondency. 
He  should  not  make  a  false  estimate  of  the  persevering  nature 
of  the  disease,  from  its  apparent  mildness,  at  the  momenttof  its 
investigation ;  nor  be  too  suddenly  elated,  at  the  seeming  success 
of  his  plan;  for  the  symptoms  of  the  "irritable  uterus"  afe  not 
uniformly  severe,  or  constantly  obstinate,  yet  there  is,  perhaps, 
no  disease  of  the  female  system  more  wayward  in  its  intensity, 
nor  more  liable  to  recurrence,  from  either  neglect  or  imprudence. 
He  should  be  well  aware  of  a  truth,  proved  by  multiplied  expe- 
rience— that  no  affection  brooks  trifling  with  so  bad  a  grace  as 
the  "  irritable  uterus ;"  and  that  all  departures  from  prescribed 
rules  is  almost  sure  to  be  followed  by  penalties  much  beyond 
the  seeming  importance  of  the  trespass. 

But,  notwithstanding  the  unyielding  nature  of  the  disease  of 
which  we  are  treating,  much  may  be  done  towards  its  relief,  if 
we  cannot  always  promise  its  removal;  and  we  are  rather  dis- 
posed to  believe  that  the  difficulty  of  its  management  arises  very 
often  from  the  impatience,  the  imprudence,  or  the  circumstances 
of  the  patient,  rather  than  from  the  insurmountable  nature  of 
the  disease  itself.  The  first  prevents  the  best  application  of  the 
remedies ;  the  second  may  defeat  their  best  operation ;  and  the 
third  will  perhaps  interrupt  their  due  employment.  Having 
thus  pointed  out  some  of  the  difficulties  inseparable  from  the 
management  of  this  disease,  and  suggested  certain  cautions,  that 
must  never  be  lost  sight  of  during  this  treatment,  we  will  now 
proceed  to  detail  all  that  experience  has  hitherto  suggested  for 
its  relief. 

The  therapeutical  means  will  consist,  first,  of  rest ;  secondly, 
of  bleeding,  both  general  and  local ;  thirdly,  of  purging ;  fourthly, 
of  blistering,  or  of  the  employment  of  rubefacients ;  fifthly,  of 
narcotics;  sixthly,  of  injections  per  vaginam;  seventhly,  of  re- 


IRRITABLE    UTERUS.  303 

gimen;  eighthly,  of  the  application  of  the  pessary;  and,  lastly, 
of  tonics. 

Of  Rest. — A  steady  and  persevering  repose  of  body  is  a  sine 
qua  non  in  the  treatment  of  a  confirmed  "  irritable  uterus."  By 
rest,  we  are  to  understand  almost  absolute  quiet  in  a  horizontal 
position.  The  patient  may  make  her  election  as  regards  the 
substance  on  which  she  is  to  repose:  it  may  be  a  bed,  a  mat- 
tress, a  couch  or  sofa;  or  she  may  occasionally  vary  either  of 
these,  provided  these  changes  are  neither  made  too  often,  nor 
too  suddenly,  nor  at  the  expense  of  the  patient's  own  exertions. 
The  patient,  for  instance,  may  be  carefully  removed  from  either 
her  bed  or  her  mattress,  to  a  couch  or  sofa,  and  this  daily,  if  she 
choose  this  change,  but  she  must  preserve  the  horizontal  position 
under  all  circumstances.  She  must  not  sit  up  even  in  the  bed, 
or  on  the  mattress  or  sofa,  even  for  a  short  time,  as  this  slight 
indulgence  is  almost  sure  to  be  followed  by  an  increase  of  pain, 
or  other  inconvenience;  a  fortiori,  she  must  not  be  permitted 
either  to  stand  for  any  time  upon  her  feet,  or  to  walk. 

Nothing  shows  the  extreme  sensibility  of  the  uterus,  (or  rather 
a  portion  of  it,)  more  decidedly,  than  that  augmentation  of  pain, 
which  almost  instantly  takes  place  from  an  erect,  or  even  a  semi- 
erect  position,  and  which  obliges  the  woman,  almost  instinctively, 
to  return  to  a  horizontal  one.  All  her  unpleasant  symptoms  are 
suddenly  increased ;  especially  the  throbbing  sensation,  which, 
as  we  have  declared  above,  so  particularly  characterizes  this 
disease.  This  increase  of  pain  most  probably  arises  from  two 
causes:  first,  from  the  uterus  being  obliged  to  sustain  much  of 
the  weight  of  the  abdominal  viscera ;  and,  secondly,  this  position 
retards  the  return  of  blood  from  these  parts. 

At  first,  the  confinement  to  bed  is  extremely  irksome ;  but  the 
patient  should  be  encouraged  to  perseverance,  by  the  assurance 
that  this  unpleasant  sensation  will  wear  off  in  a  short  time;  and 
that  she  will  not  only  become  reconciled  to  the  horizontal  posi- 
tion, but  will  absolutely  covet  it,  from  the  immediate  and  certain 
relief  she  will  experience  by  returning  to  it  after  having  sat  up 
for  a  few  minutes,  or,  sometimes  from  even  attempting  it.  The 
cause  of  this  increase  of  pain  we  have  endeavoured  to  explain 
above. 

Of  Bleeding. — First,  we  shall  say  a  few  words  upon  the  occa- 
sional necessity  of  bleeding  from  the  arm  or  foot.  We  would 
employ  general  bleeding  only  under  two  circumstances  of  the 
system — first,  where  the  circulation  is  vigorous ;  the  pulse  tense 
or  chorded;  where  there  is  much  pain,  and  especially  in  the  ab- 
domen, accompanied  by  cough  or  headache.  In  such  cases  we 
would  abstract  blood  from  the  arm,  to  an  amount  that  would 
afford  relief  even  during  its  flow,  did  this  require  but  eight  or 
ten  ounces,  or  a  much  larger  quantity:  for  we  have  uniformly 


304  IRRITABLE   UTERUS. 

found  that  the  proper  abstraction  of  hlood  from  the  system  at 
largo,  in  the  beginning  of  our  treatment,  was  sure  to  be  followed 
by  advantages  that  could  be  procured  in  no  other  way — besides, 
if  we  draw  blood  in  sufficient  quantity  at  first  from  the  arm,  we 
need  rarely  repeat  this  operation ;  while,  at  the  same  time,  its 
abstraction  gives  a  more  decided  efficacy  to  other  remedial  means. 
Secondly,  should  the  symptoms  enumerated  above  be  attended 
with  a  sparing  menstrual  discharge,  we  would  abstract  eight  or 
ten  ounces  of  blood  from  the  foot,  and  this  should  be  repeated 
five  or  six  days  before  the  next  menstrual  period,  if  the  first  has 
not  succeeded. 

But  the  "irritable  uterus"  will  require  the  abstraction  of  blood 
from  parts  near  the  seat  of  the  affection,  and  this  again  and  again 
— the  parts  hitherto  selected  for  this  purpose  have  been  the  sa- 
crum, or  the  abdomen ;  but  multiplied  experience  has  convinced 
me  that  as  much  advantage,  to  say  the  least,  but  we  really  think 
much  more  has  followed,  when  the  blood  has  been  drawn  from 
the  inner  part  of  the  thighs,  three  or  four  inches  below  the  vulva ; 
it  may  be  drawn  from  one  or  both  thighs  at  the  same  time,  by 
either  cupping  or  leeching,  and  should  be  repeated  every  four 
weeks,  a  few  days  before  the  menstrual  period,  until  pain,  &c., 
are  much  abated,  or  until  the  patient  can  bear  to  be  placed  upon 
her  feet,  or  even  walk,  without  much  inconvenience  or  discom- 
fort. Four  or  five  ounces  may  be  drawn  at  each  time. 

We  have  had,  within  the  last  year,  a  number  of  exquisitely 
formed  cases  of  this  disease ;  and  we  are  happy  to  state,  that  if 
blood  be  abstracted  by  leeches,  immediately  on  the  womb,  to  the 
amount  of  four,  five,  or  six  ounces,  (as  the  inflammation  may  be 
more  or  less  attended  by  a  high  degree  of  sensibility  of  the  ute- 
rus,) the  most  decided  advantage  will  quickly  result.  This  ope- 
ration is  one  of  less  difficulty  in  its  execution  than  would,  at  first 
sight,  be  supposed.  The  greatest  difficulty  is  to  get  the  patient 
to  submit  to  it.  It  gives  less  pain  than  leeching  from  an  exter- 
nal surface.  We  have  seen  several  cases  of  irritable  uterus  yield 
to  this  plan,  and  the  other  means,  diet,  rest,  &c.,  in  a  very  short 
time,  and  much  more  completely.  A  tube  is  introduced  into  the 
vagina,  through  which  the  leeches  are  conducted  to  the  neck  or 
other  portions  of  the  uterus.  The  after  bleeding  is  generally 
more  considerable  than  from  the  skin.  The  application  of  leeches 
to  this  organ  is  a  great  improvement  in  the  management  of  any 
of  its  affections. 

In  judging,  however,  of  the  diminution  of  pain,  it  must  be  kept 
in  view,  that  the  effects  of  long  confinement  in  a  horizontal  posi- 
tion be  not  mistaken  for  the  consequences  of  the  change  of  posi- 
tion upon  the  affected  parts.  We  should,  therefore,  inquire  into 
the  nature  of  the  existing  feelings,  and  compare  them,  both  in 
degree,  and  in  their  nature,  with  those  that  really  belong  to  the 


305 

disease.  To  aid  us,  therefore,  in  forming  a  correct  judgment 
upon  this  important  point,  we  should,  from  time  to  time,  make  a 
careful  examination  per  vaginam,  with  a  view  to  determine  the 
existing  degree  of  sensibility  in  the  neck  of  the  uterus,  and  the 
several  portions  of  the  vagina.  By  doing  this,  we  shall  be  able 
to  determine  the  exact  impression  we  are  making  upon  the  dis- 
ease ;  and,  consequently,  thereby  ascertain  the  extent  of  neces- 
sity for  perseverance.  In  making  this  estimate  we  must  never 
fail  to  take  into  consideration  the  state  or  degree  of  the  "throb- 
bing sensation"  we  have  mentioned,  as  particularly  belonging  to 
the  disease.  By  this  very  much  may  be  learned  ;  for,  if  this 
feeling  do  not  dimmish  with  the  sensibility,  we  may  be  certain 
that  the  affection  has  only  made  a  truce,  but  has  not  retrograded; 
while,  on  the  other  hand,  we  may  be  assured,  that,  in  proportion 
to  the  abatement  of  this  unpleasant  feeling,  is  the  abatement  of 
the  disease  itself. 

Purging.  —  There  is  no  one  of  the  remedies  proper  in  this 
disease  so  difficult  to  manage  as  purging  —  -for  there  is  no  doing 
with  or  without  it,  as  the  bowels  in  this  complaint  are  always 
either  constipated,  or  too  easily  made  free,  and  either  condition 
is  sure  to  aggravate  the  suffering.  In  tWs  opinion  I  am  happy 
to  be  supported  by  the  experience  c^"  Dr.  Gooch.  But,  not- 
withstanding these  difficulties,  it  i?  every  way  important  that 
the  bowels  should  be  moved  once  a  day;  neither  less  nor  more; 
—  and  for  this  purpose  nothing  answers  better  than  the  simple 
rhubarb  pill. 

Blistering  and  Rubefa'ienta.  —  We  are  much  at  a  loss  to  de- 
termine the  exact  valno  of  blistering  in  the  "irritable  uterus,'' 
as  it  has  in  some  instances,  we  have  thought,  proved  useful,  while 
in  others  we  have  /eared  it  has  proved  mischievous  ;  on  the  whole, 
therefore,  we  s«'e  distrustful  of  this  remedy.  But  not  so  of  rube- 
facients,  or  resicating  with  the  tartar  emetic  ointment.  We  have 
uniformly  found  the  mustard  bath  of  great  utility  in  this  disease, 
as  there  is  a  prevailing  coldness  of  the  feet  and  legs.  This  bath 
should  be  used  whenever  the  coldness  of  the  feet  claims  atten- 
tion, be  this  daily,  more  seldom,  or  oftener.  The  ointment 
should  be  applied  to  a  pretty  large  surface  of  the  abdomen  twice 
a  day,  until  a  pretty  extensive  vesication  is  produced,  and  re- 
peated from  time  to  time,  as  the  vesicles  may  heal,  and  as  the 
urgency  of  the  symptoms  may  require.1 

*  ' 


1  We  have  frequently  had  cause  to  lament  the  tardy  effects  of  this  ointment. 
though  pretty  well  aware  of  the  causes.  The  first  is,  the  adulteration  of  the  tar- 
tar emetic;  and  the  second,  from  the  imperfect  manner  in  which  the  ointment  is 
prepared.  We  were,  therefore,  happy  in  meeting  with  M.  Mialhe's  directions  for 
making  it.  As  the  efficacy  of  the  ointment  depends  upon  the  minuteness  of  the 
division  of  the  tartrite  of  antimony,  M.  M.  recommends  that  "a  saturated  solution 
of  it  be  made-in  cold  water,  and  that  it  be  then  precipitated  with  alcohol.  A  very 
small  quantity  of  the  latter  will  suffice,  he  says,  to  precipitate  the  tartar  emetic 
20 


306  IRRITABLE    UTERUS. 

Narcotics.— Agreeably  to  our  experience  much  caution  is  re- 
quired in  the  use  of  narcotics,  at  least  of  opium ;  for,  to  this  drug 
only,  in  one  form  or  other,  do  we  fly,  when  it  is  proper  to  sub- 
due pain  by  this  means.  Much  mischief,  we  are  persuaded,  has 
been  done  by  the  too  free  use  of  this  medicine,  when  exhibited 
to  abate  pain  (coute  qui  coute,)  when  the  disease  has  been  mis- 
taken, or  not  well  understood.  For,  as  we  have  persuaded  our- 
selves that  the  disease  is  inflammatory,  we  can  readily  under- 
stand why  opium  has  done  mischief,  or  why,  at  least,  it  has  not 
proved  always  successful.  This  opinion  must  not  be  taken  for  a 
prejudice,  or  as  one  founded  upon  a  hypothesis ;  for  the  medicine 
has  failed  in  other  hands,  as  is  abundantly  proved  by  Dr.  Gooch's 
cases.  Yet  there  is  a  period  at  which  there  is  both  propriety 
and  advantage  in  the  use  of  opium — and  this  is,  after  the  gene- 
ral febrile  symptoms  have  been  removed  or  abated,  and  when 
the  local  ones  are  diminished  in  intensity. 

The  neck  of  the  bladder,  and  the  whole  tract  of  the  urethra, 
are  sometime*  in  a  highly  sensitive  condition,  and  give  much 
pain,  especially  in  the  effort  to  pass  water ;  for  the  relief  of  which 
much  benefit  has  bt^n  derived  from  smearing  the  parts  just  men- 
tioned, morning  and  evening,  with  the  following  ointment,  con- 
ducted to  the  parts  by  tt^  point  of  the  patient's  own  finger. 

R    Ext.  Belladon.J"/--  ''S^"fam. 
Cerate  simp,  receh  preparat.         §j. — M. 

• 

When  this  period  arrives,  we  do  not  hesitate  to  give  opium, 
laudanum,  black  drop,  or  preferably  ike  sulphate  of  morphia  in 
adequate  doses  at  bed  time,  or  oftenes,  if  suffering  require. 
Opium  may  be  given  with  much  advantage  'a\  either  of  the  forms 
now  mentioned,  in  enemata,  as  well  as  by  th^  mouth.  But  we 
should  carefully  watch  the  influence  of  this  medicine  upon  both 
the  general  and  local  symptoms ;  and  if  either  be  increased  after 
its  exhibition,  or,  in  other  words,  if  it  fail  in  procuring  relief,  the 
quantity  should  be  diminished,  or  it  should  be  withheld  altogether, 
until  the  system  be  farther  relieved  of  its  susceptibility  to  stimuli. 
To  prove  how  important  an  attention  to  this  circumstance  is,  we 
need  only  refer  to  the  case  we  have  related  from  Dr.  Gooch,  where 
opium,  and  many  other  means  were  employed,  without  benefit ; 
yet  the  patient  was  almost  instantly  relieved  by  the  application 
of  a  few  leeches.  In  a  word,  if  opium  is  to  be  useful,  it  must 
only  be  employed  under  a  reduced  state  of  the  arterial  system. 

Of  Injections. — Under  this  head,  we  will  comprehend,  first, 
such  as  will  deterge  the  vagina,  and,  at  the  same  time,  sooth  the 

in  the  form  of  a  powder  of  extreme  tenuity.  The  precipitate  is  to  be  collected 
on  a  filter  and  dried.  Two  drachms  <Jf  this,  mixed  with  an  ounce  of  simple 
cerate,  will  make  a  very  active  ointment." — Amer.  Journ.  of  Med.  Sciences,  for 
February,  1831,  p.  52-2. 


IRRITABLE    UTERUS.  307 

uterus:  of  this  kind  is  lukewarm  flaxseed  or  slippery  elm  bark- 
tea:  a  quantity  of  this  should  be  thrown  up  the  vagina,  by  a 
syringe  of  sufficient  size,  three  or  four  times  a  day,  or  oftengr, 
if  suffering  be  considerable,  either  from  pain,  heat,  or  throbbing. 

The  injection  should  be  retained  for  some  time  by  applying  a 
cloth  to  the  vulva,  so  as  to  prevent  its  too  early  escape.  The 
other  is  sedative — and  may  be  composed  of  eight  grains  of  opium 
dissolved  in  a  pint  of  hot  water,  and  carefully  strained — an  ounce 
of  this  may  be  used  after  the  other  injection  has  removed  itself. 
Quere,  as  more  or  less  leucorrhoea  pretty  uniformly  attends  this 
disease,  might  not  a  weak  solution  of  the  nitrate  of  silver  be  used 
with  advantage,  as  this  remedy  is  known  to  exert  a  tranquillizing 
influence  upon  certain  inflamed  surfaces?  We  have  found  the 
"  throbbing"  much  relieved  by  introducing  a  small  piece  of  sponge 
saturated  with  equal  parts  of  laudanum  and  water,  within  the  os 
externum. 

Regimen. — The  diet  of  the  patient  should  be  most  carefully  at- 
tended to,  and  made  to  conform  to  the  general  indications; 
namely,  to  abate  inflammation,  and  to  relieve  pain ;  therefore,  an 
antiphlogistic  regimen,  strictly  so  called,  should  be  constantly 
adhered  to,  and  persevered  in,  even  for  some  time  after  the  ap- 
parent removal  of  the  disease — for,  as  noticed  before,  no  dis- 
ease bears  imprudences  worse  than  the  one  of  which  we  are 
treating. 

Of  the  Pessary. — It  frequently  happens,  that  the  uterus  will 
remain  prolapsed  after  the  sensibility  of  the  uterus  is  removed — 
when  this  is  so,  much  advantage  will  be  derived  from  the  use  of 
a  well-adjusted  pessary.  Attention,  however,  should  be  paid, 
that  it  excite  no  pain,  or  other  inconvenience,  by  its  presence ; 
if  it  should,  it  must  be  instantly  removed,  and  not  reapplied,  un- 
til the  parts  have  acquired  a  more  natural  state  of  feeling. 

Tonics. — Much  injury  is  frequently  done,  by  the  too  early 
use  of  this  class  of  remedies — in  several  instances  we  have  wit- 
nessed severe  relapses,  by  attempts  to  give  strength  to  the  body ; 
they  should,  therefore,  be  withheld  for  a  long  time,  or  perhaps 
more  safely,  altogether,  in  very  susceptible  systems.  In  two 
instances  where  the  stomach  had  suffered  much,  great  advantage 
was  found  from  the  use  of  the  phosphate  of  iron,  given  in  from 
six  to  ten  grains,  three  times  a  day. 

We  have  selected  two  or  three  cases,  that  the  general  and  lo- 
cal symptoms  of  the  "irritable  womb"  may  again  be  brought  into 
view,  and  that  the  common  routine  of  practice  may  be  the  bet- 
ter understood.  In  making  this  selection,  we  have  not  been 
governed  by  any  peculiarity  they  exhibited,  or  because  there  was 
any  particular  departure  from  the  ordinary  mode  of  treatment; 
they  have  been  chosen,  with  one  exception,  (the  third)  because  they 
were  considered  as  fair  instances  of  the  "irritable  uterus,"  and 


308  IRRITABLE    UTERUS. 

exhibited  the  most  usual  train  of  symptoms,  as  well  as  the  most 
uniform  mode  of  treatment. 

CASE  I. — Mrs. ,  aged  thirty-six,  the  mother  of  five  chil- 
dren, had  been  labouring  under  the  following  symptoms  several 
months  before  we  visited  her;  namely,  a  constant  tenderness 
immediately  behind  the  mons  veneris,  which  was  converted  into 
acute  pain  by  any  sudden  exertion  of  the  body,  especially  by 
walking  up  stairs,  or  going  down.  The  pain  experienced  upon 
such  occasions  was  of  a  lancinating  kind,  and  of  great  severity ; 
and  when  once  provoked,  would  continue  from  one  to  two  or 
three  hours,  suffering,  however,  a  gradual  abatement  during  this 
time.  This  pain  was  constantly  excited  if  she  sat  upon  a  hard 
substance,  and  she  was  therefore  obliged  to  guard  against  this 
inconvenience,  by  placing  a  soft  cushion  over  the  hole  of  a 
pierced  chair.  She  found  that  emotions  of  the  mind,  if  sudden- 
ly induced,  would  have  the  effect,  though  in  a  more  moderate 
degree  than  some  other  causes.  Coughing  or  sneezing  was 
sure  to  create  great  suffering.  Upon  examination  per  vaginam, 
the  uterus  was  found  considerably  lower  than  natural ;  its  neck 
was  exquisitely  tender,  and  larger  than  common — the  os  tincae 
very  closely  shut,  and  the  part  of  the  body  of  the  uterus  within 
reach  of  the  finger,  as  well  as  the  vagina,  were  extremely  ten- 
der; so  much  so,  indeed,  as  to  render  the  examination  a  very 
unpleasant  operation — slight  leucorrhoea,  of  a  milky  appearance ; 
the  whole  neck  of  the  bladder  was  enlarged  and  tender,  with  a 
frequent  desire  to  pass  urine,  accompanied  with  a  disagreeable 
sensation  in  the  bladder,  and  the  whole  tract  of  the  urethra. 
The  urine  was  high-coloured,  sparing,  and  deposited  largely. 
The  menstrual  discharge  was  pretty  regular  in  its  recurrence, 
proper  in  quantity,  and  employing  about  six  days  for  its  com- 
pletion. This  discharge  was  announced  always  by  tenderness 
in  the  mammae ;  a  sense  of  fulness  in  the  region  of  the  uterus, 
with  a  feeling  as  if  the  uterus  were  constantly 'sinking  lower  in 
the  pelvis — there  was  no  dysmenorrhoea,  nor  any  discharge  of 
coagula. 

The  head  was  very  frequently  attacked  by  severe  pain,  espe- 
cially on  the  back  part  of  it.  This  became  worse  almost  always 
in  the  afternoon,  at  which  time  a  slight  febrile  exacerbation  was 
sure  to  take  place,  though  the  pulse  was  always  excited  beyond 
the  natural  beat — it  was  corded,  and  not  large ;  the  skin  dry. 
and,  where  covered,  the  heat  was  above  the  natural  temperature. 
The  hands,  feet,  and  legs,  constantly  cold;  the  bowels  constipated, 
but  easily  urged  to  diarrhoea ;  the  appetite  pretty  good,  though 
variable,  and  the  digestion  not  bad.  The-  tongue  very  slightly 
furred,  and  paler  than  natural. 

She  was  ordered  to  observe  a  horizontal  position;  a  strict  an- 
tiphlogistic regimen;  to  lose  ten  ounces  of  blood  from  the  arm ; 


IRRITABLE    UTERUS.  309 

the  mustard  bath  for  the  feet  and  legs  every  other  night ;  luke- 
warm flaxseed  tea  injections  per  vaginam  three  times  a  day;  a 
rhubarb  pill  every  night  at  bed-time ;  and  to  forego  matrimonial 
privileges,  as  extreme  suffering  was  always  experienced  from 
their  indulgence. 

This  plan  was  persevered  in  for  three  weeks  without  any  re- 
markable change,  save  a  general  improvement  of  feelings.  The 
uterus  and  every  thing  else  remained  pretty  much  as  at  the  com- 
mencement of  the  plan.  Four  ounces  of  blood  to  be  taken  by 
leeohes  from  the  inner  portion  of  the  thighs — every  thing  else 
as  before.  After  the  third  month  had  elapsed,  there  was  an 
evident  melioration  of  symptoms;  especially  of  the  uterus  and 
the  surrounding  parts — their  sensibility  was  much  diminished, 
and  the  leucorrhcea  abated — during  this  time  leeches  had  been 
applied  three  times ;  the  bowels  kept  daily  open,  and  the  urine 
was  discharged  less  frequently,  and  with  more  freedom,  but  it 
still  deposited  considerably. 

Injections  of  a  weak  solution  of  the  acetate  of  lead,  (two 
grains  to  the  ounce,)  were  ventured  on ;  leeches  to  the  thigh,  as 
before ;  rest,  diet,  and  the  rhubarb  pill,  as  before. 

At  the  expiration  of  three  months  more,  symptoms  were  much 
improved;  the  plan  had  been  persisted  in  with  great  fidelity  and 
patience.  Injections  of  the  solution  of  opium  were  now  substi- 
tuted for  those  of  the  lead — a  sixth  of  a  grain  of  morphia  was 
ordered  whenever  pain  became  severe ;  for  this  had  never  failed 
to  attend,  in  a  greater  or  less  degree,  though  with  much  less  se- 
verity and  frequency  than  before.  This  lady  was  once  blistered 
on  the  sacrum,  but  with  such  doubtful  effect,  that  it  was  never 
repeated.  At  about  this  time  the  tartar  emetic  ointment  was 
rubbed  upon  the  lower  part  of  the  abdomen  until  a  copious  crop 
of  pustules  appeared,  and  with  manifest  advantage.  It  may  be 
proper  to  observe,  that  this  application  can  only  be  serviceable, 
we  believe,  after  the  violence  of  the  disease  has  abated — it  may 
be  repeated  in  three  or  four  weeks  after  the  first,  if  the  sensibi- 
lity of  the  neck  of  the  uterus  be  not  subdued — we  never  use  thia 
ointment  in  the  beginning  of  the  treatment. 

It  now  appeared  that  the  disease  was  more  certainly  under 
the  control  of  the  remedies  already  mentioned,  and  was  daily 
abating  in  severity — the  leucorrhoea  entirely  disappeared,  nor 
has  it  returned.  At  the  end  of  thirteen  months  the  patient  was 
entirely  well,  though  weak  from  long  confinement,  &c.,  and  was 
now,  and  not  until  now,  permitted  to  sit  up :  after  this  was  tried 
a  few  days,  and  apparently  with  advantage,  she  was  allowed  to 
walk  in  her  chamber,  and  rapidly  gained  strength  by  the  indul- 
gence. It  was,  however,  soon  found,  that  the  prolapsed  condi- 
tion of  the  uterus  was  offering  considerable  inconvenience ;  and 
as  the  parts  had  entirely  recovered  their  natural  condition,  a 


310  IRRITABLE    UTERUS. 

pessary  was  introduced  with  very  prompt  and  decided  advan- 
tage, and  the  patient  is  now  enjoying  a  very  comfortable  state 
of  health. 

CASE  II. — It  will  not  be  necessary  to  detail  the  symptoms  of 
this  case,  as  they  bore  an  entire  resemblance  to  the  one  just  re- 
lated. There  were,  however,  certain  points  of  difference ;  namely, 
the  patient  had  been  labouring  under  the  affection  for  several 
years,  but  had  not  derived  the  slightest  benefit  from  what  had 
been  done  for  her  relief.  It  was  looked  upon  as  a  disease  of  de- 
bility, and  the  severe  sufferings  were  supposed  to  be  caused  by 
spasm — hence,  bark,  steel,  cold  bath,  sea-bathing,  opium,  hem- 
lock, henbane,  stramonium,  warm  bath,  blistering,,  salivation, 
twice  repeated,  &c.,  &c.,  were  had  recourse  to,  but  to  no  other 
purpose  than  to  increase  debility,  without  diminishing  suffering. 
In  this  case,  pain  was  not  so  violent,  but  there  was  more  leucor- 
rhoea,  and  more  profuse  menstruation.  This  lady  was  confined 
to  her  bed  from  extreme  weakness  when  we  first  saw  her — the 
febrile  affection  was  more  distinctly  marked,  and  great  obstinacy 
of  bowels.  General  bleeding  was  not  employed  in  this  case; 
with  this  exception,  it  was  treated  like  case  first;  but  fortunately 
in  this  instance  the  patient  was  entirely  restored  in  seven  months. 
In  this  case,  like  the  former,  the  pessary  was  employed  from  the 
period  just  mentioned. 

CASE  III. — This  case  differed  from  the  two  now  related,  in 
three  important  points ;  first,  the  menses  were  very  irregular  in 
their  returns,  and  always  attended  by  hemorrhagy  to  a  very  con- 
siderable degree ;  coagula  were  expelled  in  great  numbers,  and 
after  each  spell  the  patient  was  left  much  debilitated,  though 
she  for  the  most  part  kept  about;  secondly,  there  was  profuse 
leucorrhoea  of  a  purulent  appearance;  and  thirdly,  the  neck  of 
the  uterus  was  very  much  larger  than  we  had  ever  witnessed 
before,  and  its  sensibility  was  very  great.  The  same  general 
plan  was  adopted,  and  the  patient  was  very  much  relieved  at  the 
end  of  about  five  months,  though  not  altogether  well. 

When  we  examined  the  uterus  last,  its  neck  was  reduced  to 
its  natural  size,  and  had  lost  nearly  all  its  morbid  sensibility. 
We  have  had  some  reason  to  regret  that  the  plan  which  had  so 
far  relieved  the  disease,  had  not  been  persevered  in  three  or  four 
months  longer,  as  there  was  every  reasonable  expectation  that 
it  would  have  proved  still  more  beneficial. 

Notwithstanding  the  success  that  attended  the  cases  just  re- 
lated, as  well  as  many  more  that  we  could  mention,  it  is  but  fair 
to  acknowledge,  there  have  been  others,  in  which  no  such  bene- 
fit was  received,  though  remedies,  generally  speaking,  were 
faithfully  used,  and  every  reasonable  precaution  taken  to  ensure 
success. 

From  recent  experience,  I  have  found  the  iodine  of  great  ser- 


-UTERINE    HEMORRHAGE.  311 

vice  in  this  indomitable  disease,  but  never  to  be  a  decided  remedy; 
but  much  relief  has  been  found  from  it ;  so  much  so,  that  patients 
believed  they  were  getting  well  fast,  but  it  seemed  to  have  an 
influence  so  far  and  no  farther.  It  was  given  in  the  form  of 
Lugol's  tincture,  No.  3.  It  was  commenced  by  ordering  six 
drops  every  morning,  noon,  and  evening,  in  some  sweetened 
water,  and  increased  very  gradually  to  thirty  drops.  It  abated 
many  of  the  symptoms  very  sensibly,  especially  the  pain  and 
constant  uneasiness  that  was  felt  in  the  vagina,  and  rendered 
coition  when  it  was  indulged  in  much  more  tolerable. 


.pAPTER  XVI.  4 

19  3,'JJ*' 

ON  UTERINE  HEMORRHAGE.1 

fjti 

THE  mode  I  shall  pursue  in  treating  this  subject,  will  be, 

First,  To  consider  very  briefly  the  nature  of  the  connexion  of 
the  ovum  with  the  internal  surface  of  the  uterus. 

Secondly,  To  investigate  the  causes  which  may  impair  this 
connexion,  and  thus  expose  the  surface  from  which  the  blood  is 
derived. 

Thirdly,  To  examine  into  the  mode  of  action  of  these  agents, 
in  effecting  this  lesion. 

Fourthly,  To  point  out  the  several  periods  of  utero-gestation, 
at  which  this  lesion  may  take  place  —  and  trace  the  various  con- 
sequences which  may  result  from  it,  at  these  several  periods. 

Fifthly,  To  notice  the  modes  of  treatment  at  these  different 
stages,  and  under  these  various  circumstances. 

' 


SECT.  I.  —  1.  The  Connexion  of  the  Ovum  with  the  Uterus. 

Soon  after  the  ovum  is  deposited  within  the  cavity  of  the  ute- 
rus, we  find  it  connected,  through  the  whole  extent  of  its  surface, 
with  the  internal  face  of  this  organ.  The  uterus  and  ovum  mu- 
tually contribute  to  this  end:  on  the  part  of  the  womb,  we  find  it 
produce  a  soft  spongy  substance,  called  decidua  ;  on  the  part  of 
the  ovum,  we  discover  its  external  covering,  or  chorion,  shooting 

1  Of  this  disease,  the  unavoidable  species,  we  have  thought,  only  belonged  pro- 
perly to  midwifery;  consequently,  that  which  arises  from  the  "  implantation  of 
the  placenta  to  the  mouth  of  the  uterus,"  is  not  treated  of  here,  only  the  acci- 
dental variety. 


312  UTERINE    HEMORRHAGE. 

out  innumerable  vascular  fibres — and  both,  when  united,  serve 
as  the  bond  of  union  between  the  ovum  and  the  uterus. 

The  efflorescence  on  the  uterine  surface,  like  that  which  covers 
the  ovum,  is  decidedly  vascular;  and  it  seems  that  these  minute 
vessels  interlock  with  each  other  after  a  certain  period,  and  this 
so  firmly,  that  they  cannot  be  well  separated  without  rupture. 
Therefore,  should  a  portion  of  the  ovum  be  detached  in  the  ear- 
lier months,  the  quantity  of  blood  that  will  issue  will  be  com- 
mensurate with  that  surface ;  especially,  if  it  be  from  the  body 
or  fundus. .  And,  as  a  general  rule,  it  may  be  said  that  the 
quantity  of  blood  which  may  be  expended  will  be  in  proportion 
to  the  advancement  of  pregnancy. 

SECT.  II. — 2.  TheCauses  whichmay  tend  to  destroy  this  Connexion. 

If  we  consult  authors  upon  this  subject,  we  shall  find  a  variety 
of  causes  enumerated,  as  capable  of  destroying,  to  a  greater  or 
less  extent,  the  connexion  between  the  placenta  and  uterus — and 
it  is  agreed,  by  far  the  greater  number,  that  no  considerable  he- 
morrhage can  occur  unless  this  happen. 

In  enumerating  the  remote  causes  of  hemorrhage,  I  shall  only 
name  such  as  are  most  generally  believed  to  be  capable  of  this 
effect,  either  before  or  after  delivery. 

Before  delivery:  1st,  too  short  a  funis;  2d,  mechanical  vio- 
lences; 3d,  passions  or  emotions  of  the  mind;  4th,  plethora; 
and,  after  delivery,  1st,  atony ;  2d,  spasm ;  3d,  humoral  engorge- 
ment; 4th,  unequal  contraction  of  the  uterus;  5th,  inversion. 

Though  all  these  causes  have  been  assigned  for  the  diseases 
we  are  considering — still,  it  is  sufficiently  difficult  of  explanation 
how  some  of  them  act  to  produce  it.  When  violence  of  any 
kind  is  offered  a  pregnant  woman,  and  she  miscarry,  or  is  pre- 
maturely delivered,  the  cause,  from  its  force  or  extent,  appears, 
at  first  sight,  capable  of  the  end;  and  there  all  investigation 
ceases.  It  may  not,  therefore,  be  time  ill-spent,  to  inquire  into 
their  respective  agencies. 

SECT.  III. — 3.  Mode  of  Action  of  certain  of  the  remote  Causes. 

,  _  »  I.'-''!''  .5LlU.       ..r 

And,  first,  too  short  a  cord.  It  was  the  opinion  of  La  Motte, 
that  the  cord  may  be  naturally  or  accidentally  too  short — and  that 
in  either  case,  it  might  be  the  cause  of  hemorrhage.  He  gives  a 
case  purporting  to  be  illustrative  of  this  assumption — but  con- 
fesses it  was  the  first,  and  only  one,  he  ever  met  with.  The 
bleeding  proceeded  from  one  of  the  umbilical  vessels,  at  a  portion 
which  was  folded  into  a  kind  of  knot,  and  which  yielded,  from 


UTERINE   HEMORRHAGE.  313 

the  accidental  shortness  of  the  funis.  Levret  met  with  a  similar 
instance.  And  Baudelocque  also  mentions  a  remarkable  case  of 
this  kind.1  It  must,  however,  be  confessed  by  all  conversant 
with  the  practice  of  midwifery,  that  though  this  may  be  a  cause 
of  hemorrhage,  it  must  be  a  very  rare  one — or  the  extensive 
practice  of  these  three  celebrated  authors  would  have  furnished 
more  examples. 

Secondly,  mechanical  violence:  Thirdly,  passions,  or  emotions 
of  the  mind:  Fourthly,  plethora.  Each  of  these  causes  may  pro- 
duce uterine  hemorrhage ;  and  perhaps  all  have.  However,  the 
mode  in  which  they  effect  this  is  not  so  well  understood  as  it 
deserves  to  be — the  whole  of  these  causes  have  one  common 
operation  upon  the  system — they  all  induce  increased  force  of 
circulation;  and  this  is  generally  considered  sufficient,  under 
certain  circumstances,  to  produce  the  evil  in  question.  It  has 
been  thought,  that  whatever  gave  an  increase  of  force  or  velo- 
city to  the  circulatory  system  of  the  mother,  must  almost  neces- 
sarily, in  consequence  of  the  large  size  of  the  hypogastric  and 
spermatic  arteries ;  the  short  distance  they  have  to  travel  be- 
fore they  arrive  at  the  uterus ;  and  their  great  increase  in  that 
viscus  as  gestation  advances,  very  much  affect  the  condition 
of  the  ovum  within  its  cavity — and  that  the  arterial  vis  a  tergo 
must  act  mechanically  upon  the  ovum ;  and  by  mere  force  of 
circulation  drive  it  from  its  connexion  with  the  uterus.  That 
plethora  must  also  act  after  pretty  much  the  same  manner — and 
as  a  proof  of  this,  it  is  said,  that  the  periods  at  which  the  menses 
are  wont  to  return,  are  those  at  which  the  abortion  is  most  readily 
provoked :  for,  at  these  times,  though  the  uterus  is  impregnated, 
and  this  discharge  has  ceased,  still  the  blood  is  sent  in  greater 
abundance  than  usual,  until  the  demands  of  the  embryo  are  such 
as  to  employ  it,  without  suffering  the  vessels  to  become  en- 
gorged. 

Now,  if  a  mere  increase  of  circulation  were  all  that  is  required 
to  effect  this  end,  no  woman  would  escape  aborting,  who  might 
labour  under  high  arterial  action — thus,  fevers  of  all  kinds  would 
be  followed  by  this  accident;  but  this  is  contrary  to  all  expe- 
rience. I  am  obliged,  then,  to  suppose  that  something  more  is 
necessary  than  an  invigorated  circulation. 

I  have  said,  that  something  more  is  required  than  an  increased 
force  of  circulation,  to  effect  a  separation  of  the  ovum  in  the 
early  months,  or  of  the  placenta  in  the  more  advanced  periods 
of  pregnancy — and  that  something  I  believe  to  be  uterine  con- 
traction ;  as,  without  this,  I  am  at  a  loss  to  understand  the  modus 
agendi  of  the  remote  causes. 

I  shall  not  pretend  to  say  how  the  causes  just  enumerated  in- 

1  Midwifery,  par.  1084. 


814  UTERINE   HEMORRHAGE. 

duce  this  action — though  I  am  certain  that  this  effect  is  produced 
through  their  agency,  and  for  the  following  reasons :  1st,  Because 
mere  circulatory  impulse  appears  from  the  anatomy  of  the  uterus 
and  ovum  to  be  inadequate  to  this  effect — since  neither  abortion 
nor  premature  delivery  follows  as  a  consequence,  when  this  con- 
dition has  been  present  in  its  highest  degree. 

2dly.  Because  contraction,  in  every  instance,  is  essential  to 
the  separation  of  the  placenta,  whether  in  cases  of  abortion,  pre- 
mature labour,  or  delivery  at  full  time. 

3dly.  Because  we  frequently  detect  this  cause,  by  the  presence 
of  pain,  hours  or  sometimes  even  days.,  before  the  eruption  of 
blood;  and  because,  so  long  as  this  contraction  continues,  hemor- 
rhage will  not  cease,  unless  we  diminish  the  bulk  of  the  ovum,  or 
interrupt  its  return  by  proper  remedies. 

Where  the  ovum  is  about  to  be  cast  off,  either  in  the  early  or 
later  periods  of  pregnancy,  or  where  there  is  no  chance  of  its 
preservation  from  the  effect  already  produced  upon  it,  contrac- 
tion becomes  useful,  though  originally  the  cause  of  the  separation 
and  hemorrhage,  as  it  proves  the  healthy  disposition  of  the  uterus ; 
at  least  so  far  as  this  circumstance  is  concerned.  By  it,  the 
ovum  is  completely  separated,  and  cast  off;  the  bleeding  put  a 
stop  to,  and  the  woman  secured  from  danger.  Contraction  and 
pain  are  now  to  be  contended  with,  as  well  as  the  bleeding ;  and 
these  always  increase  the  difficulty  of  cure. 

Therefore,  it  may  not  be  amiss  to  inquire  how  far  we  may 
have  a  control,  or  whether  we  have  any,  over  uterine  contrac- 
tion after  it  has  once  been  called  into  action.  The  no  small 
authority  of  Mr.  Burns  is  against  me  when  I  say,  I  think  we 
have  ;  though  confessedly,  it  is  difficult  of  subjection.  Yet,  as  it 
is  a  matter  of  high  consequence  to  ascertain  the  truth  upon  this 
subject,  I  hope  to  be  forgiven  if  I  differ  from  this  respectable 
writer.  He  says,  "  When  abortion  is  threatened,  the  process  is 
very  apt  to  go  on  to  completion,  and  it  is  only  by  interposing 
before  the  expulsive  efforts  are  begun,  that  we  can  be  successful 
in  preventing  it ;  for  whenever  the  muscular  contraction  is  uni- 
versally established,  marked  by  regular  pains,  and  attempts  to 
distend  the  cervix  and  os  uteri,  nothing,  I  believe,  can  check  the 
process." 

That  it  is  a  matter  of  uncertainty  whether  we  succeed  in  our 
attempts  to  arrest  uterine  contraction  after  it  is  "established," 
must  be  acknowledged.  But  that  it  is  never  attended  by  success, 
I  cannot  concede ;  nor  should  the  principle  be  inculcated,  as  it 
paralyzes  exertion,  and  makes  us  withhold  from  the  suffering 
female  an  attempt  which  rarely  fails  to  give  at  least  comfort. 
My  experience  would,  I  think,  in  more  instances  than  one,  de- 
clare that  I  have  been  rewarded;  and  should  our  attempts  fail 
nineteen  times  out  of  twenty,  we  are  surely  not  justified  in  with- 


UTERINE    HEMORRHAGE.  315 

holding  them.     I  therefore  make  it  an  invariable  rule  to  treat 
the  case  as  if  success  were  to  follow. 

There  is  one  case  or  condition,  I  acknowledge,  with  which  I 
never  interfere,  under  the  slightest  prospect  of  success;  and  that 
is,  where  the  process  of  gestation  has  ceased;  of  the  signs  of 
which  there  is  but  one  absolutely  certain ;  namely,  where  the 
breasts  have  become  tender  and  tumid,  and  then  pretty  suddenly 
subside.  It  would  here  be  a  forlorn  hope  to  administer  remedies 
with  a  view  of  retaining  the  ovum. 

I  am  disposed  to  believe  that  this  circumstance  is  the  only  one 
which  marks  the  loss  of  life  of  the  ovum  with  sufficient  certainty; 
it  is  perhaps  the  only  one  that  is  unequivocal ;  since  all  others 
may  be  said  to  be  deceptive.  This  mark  was  known  to  Hippo- 
crates ;  and  has,  I  believe,  ever  since  his  time,  stood  the  test  of 
experience.  So  long,  then,  as  this  sign  be  absent,  I  do  not  relax 
in  my  attempts  to  preserve  the  ovum.  It  must,  however,  be  con- 
fessed, that  I  have  known  the  ovum  to  be  cast  off,  where  this 
symptom  was  wanting.  Yet  I  am  persuaded,  in  each  of  these 
instances,  that  the  ovum  preserved  its  vitality  almost  to  the  last 
moment;  and  that  its  expulsion  was  owing  to  the  indomitable 
nature  of  the  contractions  of  the  uterus :  I  think  this  has  ob- 
tained most  generally  with  women  who  are  in  the  habit  of  mis- 
carrying. I  do  not  stand  alone  in  my  opinion  upon  this  subject. 

Puzos,  (Mem.  de  1'Acad.  de  Chirur.  vol.  i.  p.  203,)  declares, 
that  neither  pain  nor  hemorrhage  necessarily  produces  abortion. 
La  Motte,  (Obs.  305,)  gives  an  instance  where  the  woman  went 
her  full  time,  after  the  orifice  of  the  uterus  was  considerably  di- 
lated. And  above  all,  I  may  cite  Mr.  Burns,  himself,  for  an  ex- 
ample most  strictly  in  point.  (Princip.  of  Mid.  ed.  2d,  p.  195, 
in  a  note.)  He  relates,  with  seeming  belief,  that  cases  have  oc- 
curred of  twins,  one  of  which  has  been  expelled,  while  the  other 
remained,  and  the  "action  of  gestation,"  as  he  happily  terms  it, 
was  still  maintained  to  the  proper  period.1 

Now,  this  clearly  demonstrates  that  after  muscular  action  has 
been  "universally  established,"  it  can  be  suspended  for  a  con- 
siderable time.  If  this  be  so,  under  the  circumstance  of  one  fetus 
being  expelled,  and  the  uterus,  by  a  cessation  of  action,  permit 
a  second  to  remain  until  the  proper  time,  I  should  expect  it,  & 
fortiori,  when  the  uterus  is  not  so  extensively  or  so  powerfully 
excited. 

The  remote  causes  which  I  have  hitherto  been  tracing  may 
with  propriety  be  considered  as  contingent,  or  accidental  in  their 
application  and  influence.  But  one  still  remains  to  be  noticed, 

1  Indeed,  our  periodical  journals  have  lately,  in  a  number  of  instances,  fur- 
nished us  with  cases,  proving  that  the  uterus  may  expel  a  fcetus  prematurely,  and 
then  become  passive,  until  a  twin  was  matured,  or  in  a  condition  to  be  expelled 
with  advantage  to  itself. 


316  UTERINE    HEMORRHAGE. 

which  must  be  regarded  as  absolute  in  its  effects,  whenever  it 
may  chance  to  exist  —  I  allude  to  the  implantation  of  the  placenta 
over  the  mouth  of  the  uterus. 

The  knowledge  of  this  particular  location  of  the  placenta  is  of 
modern  discovery  —  and,  perhaps,  Levret  is  the  first  who  de- 
cidedly taught  this  doctrine.  Mauriceau,  La  Motte,  and  others 
before  his  time,  met  with  the  placenta  in  this  situation,  but  they 
all  believed  it  was  a  mere  falling  down  of  this  mass  to  the  mouth 
of  the  uterus,  after  its  entire  separation  from  the  fundus. 

But  when  thus  placed,  flooding  is  inevitable  ;  for  the  order  of 
development  of  the  uterus  is  so  uniform,  that  a  deviation  can 
only  result  from  accident,  or  such  a  combination  of  circumstances 
as  very  rarely  happens  :  we  can  then  with  absolute  certainty  de- 
clare, that  when  the  placenta  is  unhappily  situated  over  the 
mouth  of  the  uterus,  a  flooding  towards  the  latter  periods  of 
gestation  must  happen,  —  hence  the  propriety  of  the  term  "un- 
avoidable," for  this  kind  of  hemorrhage. 

During  the  first  six  months  of  utero-gestation,  the  body  and 
fundus  alone  yield  to  the  distending  power  of  the  ovum  :  after 
this  time  the  neck  is  called  upon,  (if  I  may  so  term  it,)  for  its 
proportion,  as  the  other  parts  of  this  organ  seem  to  refuse  any 
farther  supply;  in  consequence  of  which,  it,  in  its  turn,  becomes 
distended  ;  and,  in  this  act,  a  portion  of  the  placenta  is  neces- 
sarily removed  ;  and  a  bleeding,  according  to  the  extent  of  injury, 
or  the  number  of  vessels  exposed  or  ruptured,  ensues. 

After  discharging  more  or  less  blood,  the  hemorrhage  may 
cease  ;  or  it  may  be  so  reduced  in  quantity,  as  to  excite  little 
apprehension.  But  this  is  a  false  security  —  it  is  sooner  or  later 
renewed,  either  by  a  farther  stretching  of  the  neck,  by  the  aug- 
mentation of  the  ovum,  or  by  the  removal  of  the  coagulum, 
which  had  until  now  stopped  the  bleeding. 

In  this  manner  may  things  proceed,  until  near  the  last  stage 
of  pregnancy  —  or  the  extent  of  separation  may  be  such,  or  the 
size  of  the  vessels  exposed  be  so  large,  that  the  woman's  life  is 
instantly  jeopardized,  and  from  which  she  can  only  be  protected 
by  the  most  prompt  and  efficient  remedies.1 


(  j  . 

SECT.  IV.  —  4.  TJie  Periods  of  Pregnancy  at  which  Hemorrhage 
may  take  place. 


There  is  no  period  at  which  hemorrhage  may  not  take  place, 
after  the  first  month  of  pregnancy;  since  it  is  presumable,  that 
after  the  fourth  or  fifth  week,  a  union,  more  or  less  strict,  is 

1  For  a  particular  account  of  this  cause  of  hemorrhage,  and  its  mode  of  treat- 
ment, see  system  of  Midwifery  by  the  author. 


UTERINE  HEMORRHAGE.  317 

formed  between  the  ovum  and  the  uterus,  by  means  of  the  cho- 
rion  and  the  decidua.  It  must,  therefore,  necessarily  follow  that 
a  separation  may  be  effected,  and,  if  this  happen,  a  bleeding  must 
ensue.  Until  about  the  fourth,  or  between  the  fourth  and  the 
fifth  month  of  gestation,  this  separation  may  happen  to  any  por- 
tion of  the  ovum ;  as,  up  to  this  period,  the  placenta,  or  what  is 
to  become  placenta,  completely  surrounds  the  ovum. 

As  a  general  rule,  then,  we  find  the  danger  from  floodings  in 
proportion  to  the  advancement  of  pregnancy ;  because  the  vessels 
are  larger,  and  will,  in  a  given  time,  yield  a  much  greater  quan- 
tity of  blood — though  the  chance  of  hemorrhage  taking  place  is 
greater  in  the  earlier  months.  Puzos  says  that  abortions  under 
the  fourth  month  are  rarely  fatal ;  and  this  observation,  perhaps, 
would  be  confirmed  by  the  experience  of  almost  every  practi- 
tioner, provided  a  sufficiently  early  attention  may  have  been 
paid  to  it.  jjtiA.-'  *ul 

It  must,  however,  be  confessed  that  it  is  very  difficult  to  esta- 
blish any  certain  rule  upon  this  subject,  since  I  have  seen  symp- 
toms as  alarming  attend  an  abortion  of  six  weeks,  as  I  have  wit- 
nessed from  a  premature  labour  of  the  seventh  month ;  or,  indeed, 
at  any  other  period.  It  may,  however,  with  confidence  be  ad- 
vanced, that  alarming  symptoms  do  not  show  themselves  as 
quickly  in  the  early  as  in  the  latter  months ;  and,  of  course,  we 
have  much  more  time  for  the  employment  of  proper  remedies. 

We  shall  now  consider  the  mode  of  treatment.  In  pursuing 
my  inquiry  into  this  part  of  my  subject,  I  shall  endeavour  to  be 
as  explicit  as  the  nature  of  the  subject  will  admit;  for  I  can  only 
establish  general  principles,  and  modes  of  management;  as,  per- 
haps, each  individual  case  will  present  a  shade  of  difference ;  and 
the  treatment  of  this  shade  of  difference,  whether  important  or 
otherwise,  must  be  very  much  left  to  the  good  sense  and  judgment 
of  the  practitioner.  I,  however,  trust,  at  the  same  time,  that 
little  embarrassment  will  be  experienced,  as  the  indications  and 
their  fulfilment  will  be  so  distinctly  pointed  out,  as  to  render 
the  one  pretty  certain,  and  the  other  without  much  ambiguity. 

With  a  view  to  perspicuity,  I  shall  divide  the  consideration  of 
floodings  into  the  several  periods  at  which  they  may  appear,  and 
the  remedies  into  their  nature,  or  supposed  mode  of  action.  The 
peculiarities  of  each  period  will  be  pointed  out :  by  doing  which, 
we  can  establish  more  clearly  and  certainly  the  mode  of  treat- 
ment. The  nature  of  each  remedy  shall  also  be  considered,  and 
the  period  at  which  it  is  more  especially  indicated ;  together  with 
its  mode  of  action,  and  the  degree  of  confidence  to  be  placed  in  it. 

In  the  division  of  this  part  of  my  subject,  I  shall  nearly  follow 
the  arrangement  of  Dr.  Denman,  as  it  embraces  every  essential 
variety  of  period  at  which  hemorrhage,  as1  a  consequence  of  ute- 
ro-gestation,  may  take  place.  This  will  consist  of  four  periods. 


318  UTERINE   HEMORRHAGE. 

1st.  That  period  at  which  the  ovum  is  entirely  surrounded  by 
the  decidua  and  decidua  reflexa:  this  will  comprehend  the  first 
four  or  four  and  a  half  months  of  pregnancy.  2d.  Into  the 
remaining  period  of  utero-gestation.  3d.  Into  the  period  be- 
tween the  birth  of  the  child,  and  the  expulsion  of  the  placenta. 
4th.  Into  the  period  subsequent  to  its  expulsion. 

This  division  is  by  no  means  arbitrary ;  it  is  founded  upon 
principles  and  circumstances  that  must  not  carelessly  be  lost  sight 
of,  if  we  wish  either  to  understand  the  nature  of  the  disease  in 
question,  or  become  acquainted  with  its  most  successful  mode  of 
treatment.  For  instance,  until  after  the  time  pointed  out  in  our 
first  division,  it  would  be  highly  improper,  under  almost  any  cir- 
cumstance, to  pierce  the  ovum  with  a  view  to  the  discharge  of 
the  liquor  amnii;  yet,  at  the  second  period,  it  may  become  an  es- 
sential remedy.  In  the  third,  the  woman's  safety  may  depend 
upon  the  immediate  delivery  of  the  placenta.  And  the  fourth, 
upon  procuring  the  tonic  contraction  of  the  uterus ;  and  each  of 
these  distinctions  should  be  well  understood,  for  upon  them  is  the 
conduct  of  the  practitioner  to  be  regulated. 

First  Period. 

*T        £  j-.,,    •fi*i'"t>»ll  "LD"!*!  "•Jt)   i!-   fcl>    • 

Until  the  period  of  four  and  a  half  months,  or  even  to  the  fifth, 
the  ovum,  when  separated  entire  from  the  uterus,  appears  to  be 
an  ovular,  spongy,  fleshy  mass;  it  bears  evidence  of  attachment 
to  the  parietes  of  the  uterus,  in  every  point  of  its  surface — and  it 
would  seem  to  show,  that  at  any  one  part  of  this  it  may  be  sub- 
ject to  separation;  and  this  separation  will  necessarily  constitute 
a  solution  of  continuity  of  more  or  less  vessels;  and  a  consequent 
hemorrhage.  I  have  just  intimated  that  this  separation  may  be 
at  any  point  of  the  ovum ;  but  the  effects  will  be  in  some  measure 
different,  as  it  may  happen  near  the  neck,  at  the  body,  or  at  the 
fundus  of  the  uterus.  If  the  separation  happen  at  the  body  or 
fundus,  the  blood  proceeding  from  the  lesion  must  increase  the 
mischief,  by  separating  other  portions  of  the  connecting  medium 
of  the  ovum  and  uterus,  before  it  can  issue  from  the  os  tincee;  it 
will,  therefore,  follow,  that  when  this  takes  place,  the  chance  of 
arresting  a  flooding,  and  preserving  the  ovum,  must  be  diminished 
in  proportion  to  the  destruction  of  the  connecting  medium.  But 
when  the  disunion  takes  place  near  the  neck,  the  mischief  will 
be  less  serious,  though  the  discharge  may  be  very  abundant. 

It  has  been  thought  by  some  that  the  os  tincge  was  always 
soon  affected  in  cases  of  hemorrhage  threatening  abortion.  But 
I  am  disposed  to  think  that  the  uterus  has  been  supposed  to  be 
open  merely  because  clots  were  expelled  from  the  vagina — but 
this  is  by  no  means  a  proof  of  an  open  condition  of  the  os  uteri; 


UTERINE   HEMORRHAGE.  319 

for  the  coagula  are  always,  perhaps,  but  certainly  much  the  most 
frequently,  formed  in  the  vagina,  when  an  ovum  occupies  the  ca- 
vity of  the  uterus.  Of  this  the  most  decisive  proof  can  often  be 
given,  in  the  very  early  months  of  pregnancy,  by  a  mere  survey 
of  the  size  of  an  expelled  coagulum;  for  many  times,  it  is  five 
or  six  times  the  bulk  of  the  uterine  cavity. 

But  little  information  can  be  derived  from  an  examination  of 
the  state  of  the  uterus  in  the  commencement  of  a  flooding  at  this 
time;  for  the  os  tincse  may  be  completely  closed  for  a  long  time, 
in  some  instances,  though  the  ovum  may  be  eventually  cast  off; 
while  in  others,  it  may  be  naturally  a  little  open,  without  offering 
additional  risk  to  the  embryo. 

But  I  may  safely  declare,  when  the  neck  of  the  uterus  is  dis- 
tended, so  as  to  resemble  in  feel  the  extremity  of  an  egg,  that 
abortion  will  sooner  or  later  take  place,  however  small  the  open- 
ing of  the  os  tincse  may  be.  In  this  case  the  uterus  is  thrown  into 
complete  action,  and  the  extension  of  the  neck  of  the  uterus,  just 
spoken  of,  is  the  effect  of  these  contractions.  There  is  another 
mark  equally  unequivocal ;  and  to  which  it  may  be  proper  now 
to  advert,  namely,  the  cessation  of  morning  sickness  ;  a  diminu- 
tion of  the  abdominal  tumour ;  but,  above  all,  the  mammae  be- 
coming painful  and  distended  with  milk,  and  these  pretty  quickly 
followed  by  flaccid  breasts.  In  both  of  these  cases,  all  attempts 
to  save  the  ovum  will  be  unavailing ;  and  our  whole  care  must  be 
directed  to  the  state  of  the  flooding. 

Nor  is  the  quantity  of  blood  expended,  in  itself,  however  exces- 
sive, positive  evidence  that  abortion  will  take  place ;  especially 
when  unaccompanied  by  pain — for  I  have  repeatedly  seen  a -very 
large  waste,  without  any  other  evil  attending ;  while,  on  the  con- 
trary, I  have  witnessed  the  expulsion  of  the  ovum  with  the  loss  of 
a  very  few  ounces,  when  accompanied  by  pain.1  As  a  general 
rule,  perhaps,  it  may  be  said  that  flooding  following  any  violence, 
more  certainly  ends  in  abortion,  than  those  which  come  on  silently 
and  slowly,  without  any  apparent  cause. 

No  reliance  should  be  placed  upon  the  opinion,  that  a  mode- 
rate discharge  of  blood  from  the  vagina  during  pregnancy,  is  use- 
ful by  removing  topical  plethora.2  On  the  contrary,  we  should 
look  upon  every  appearance  of  this  kind  with  great  suspicion, 
and  treat  it  as  if  it  were  to  become  decidedly  mischievous.  There- 
fore every  sanguineous  discharge  from  the  vagina  of  a  pregnant 
woman  should  be  treated  with  the  utmost  care — all  the  essential 

1  Pain  accompanying  flooding  should  not  make  us  abate  our  endeavours  to  save 
the  ovum,  but  under  the  circumstances  stated  above,  for  I  have  seen  ii  preserved; 
while  I  have  witnessed  several  instances  of  ova  being  cast  off,  where  neither  pain 
nor  flooding  accompanied  the  expulsion. 

*  Kok  says  that  local  plethora  is  a  cause  of  hemorrhage.     (See  Pasta,  p.  275.) 


320  UTERINE   HEMORRHAGE. 

indications  for  hemorrhage  should  be  instantly  complied  with; 
and  no  time  should  be  lost  by  temporizing. 

The  essential  indications  are,  1st,  to  arrest  the  bleeding ;  2d, 
subdue  pain,  if  present ;  and,  3d,  prevent  a  recurrence  of  the  he- 
morrhage. 

These  three  points  are  constantly  to  be  kept  in  view,  as  the 
preservation  of  the  ovum,  or  even  of  the  woman,  is  dependent 
upon  their  fulfilment.  Therefore,  whenever  a  woman  is  attacked 
with  hemorrhage  from  the  uterus,  the  sooner  it  be  arrested  the 
better:  every  known  remedy  of  efficacy  is  to  be  employed  in  suc- 
cession, should  the  antecedent  ones  fail  of  success;  and  every  ad- 
vantage must  be  given  to  these  means,  by  the  patient  and  her 
attendants,  by  a  strict  adherence  to  the  directions  enjoined.  It 
would  be  in  vain  for  the  physician  to  prescribe,  if  either  the  pa- 
tient or  attendants  run  counter  to  his  instructions ;  and  in  no 
case,  perhaps,  is  their  observance  of  more  decided  consequence 
than  in  the  complaint  we  are  now  considering. 

One  of  the  first  steps  to  be  taken  is  to  command  the  most  per- 
fect possible  rest  of  body  and  of  mind.  The  patient  should  be 
placed  upon^t  mattress,  sacking-bottom,  or  even  the  floor,  in  pre- 
ference to  a  feather-bed.  The  room  should  be  well  ventilated ; 
the  patient  very  thinly  covered ;  her  drinks,  toast-water,  cold 
balm-tea,  lemonade,  ice-water,  &c. — No  stimulating  substance  of 
any  kind  should  be  permitted.  Care  should  be  taken,  even  in  the 
administration  of  food  and  of  drinks,  that  the  patient  does  not 
exert  herself  to  receive  them ;  she  should  be  strictly  confined  to 
a  horizontal  position.  Her  food  should  be  of  the  same  general 
character  as  her  drinks — such  as  thin  sago,  tapioca,  gruel,  or  pa- 
nada— in  neither  of  these  should  wine,  or  any  other  liquor,  find 
admission;  they  can  be  rendered  agreeable  by  lemon  juice,  sugar, 
or  nutmeg.  All  animal  food,  or  the  juices  of  them,  in  the  com- 
mencement of  a  flooding,  should  be  forbidden.  Let  "'whatever  is 
given,  be  given  cool.  Absolute  rest  of  every  member  of  the  body 
should  be  enjoined. 

The  officiousness  of  nurses  and  of  friends  very  often  thwarts 
the  best  directed  measure  of  the  physician,  by  an  overweening  de- 
sire to  make  the  patient  "  comfortable."  This  consists  in  changing 
of  cloths,  "putting  the  bed  to  rights,"  or  altering  her  position.  All 
this  should  be  strictly  forbidden.  Conversation  should  be  pro- 
hibited the  patient ;  and  all  company  excluded.  Much  mischief 
is  sometimes  done  by  the  talking  of  the  by-standers ;  for  they, 
for  the  most  part,  delight  in  the  marvellous,  and  relate  the  his- 
tories of  cases  every  way  calculated  to  appal  the  already  too 
much  alarmed  patient.  This  kind  of  gossiping  should  be  pe- 
remptorily forbidden,  even  at  the  risk  of  giving  oflence,  rather 
than  permitted,  to  the  certain  injury  of  the  sick.  u-»;  ,- 

Having  established  a  proper  system  for  the  repose  of  the  pa- 


r.  :;•_>/! 


UTERINE   HEMORRHAGE.  321 

tient,  and  the  government  of  the  attendants,  we  should  next  de- 
termine the  propriety  of  blood-letting — this  becomes  very  often 
of  high  importance;  especially  at  this  division  of  our  subject: 
plethora  is  a  usual  attendant  at  this  time;  nay,  may  be,  as  I  have 
hinted  above,  the  very  cause  of  the  alarm.  Blood  should  be  taken 
from  the  arm  in  a  quantity  proportionate  to  the  force  of  the  ar- 
terial system ;  remembering  we  do  little  or  no  good  by  the  ope- 
ration, if  we  do  not  decidedly  diminish  the  force  of  its  action ; 
let  the  pulse  rather  sink  under  the  finger  than  otherwise ;  its  re- 
petition must  be  regulated  by  circumstances ;  recollecting,  how- 
ever, that  hemorrhage  is  sometimes  maintained  solely  by  exalted 
arterial  action ;  as  the  following  case  will  very  clearly  show. 

I  was  called  to  Mrs.  B.  in  January,  1796,  whom  I  found  much 
exhausted  by  uterine  hemorrhage,  in  the  fourth  month  of  gesta- 
tion. She  had  several  days  previous  to  my  visit,  returns  of 
flooding,  which  were  little  attended  to.  The  usual  means  were 
now  employed,  and  for  the  time,  the  discharge  was  arrested; 
this  was  early  in  the  morning  of  the  16th.  She  remained  very 
well  until  5  o'clock,  P.  M.  At  this  time  she  had  a  return  of 
flooding:  I  was  instantly  sent  for;  and,  living  but  a  few  steps 
from  the  patient,  was  very  quickly  at  her  bed-side.  She  was 
found  to  be  flooding  very  rapidly ;  the  pulse  was  very  active ;  and 
the  eruption  of  blood  appeared  to  have  been  preceded  by  a  slight 
rigour,  followed  by  high  arterial  action ;  she  was  instantly  bled 
from  the  arm,  until  there  was  a  reduction  in  the  force  and  fre- 
quency of  the  pulse ;  and  the  abdomen  covered  with  ice  and  snow. 
So  soon  as  this  took  place,  there  was  an  abatement  of  the  dis- 
charge ;  this  condition  was  followed  by  slight  alternate  pains  in 
the  back,  shooting  towards  the  pubes.  Forty-five  drops  of  lau- 
danum were  now  given;  and  strict  injunctions  left,  that  the  patient 
should  be  kept  as  quiet  as  possible:  and  in  case  of  return  of  the 
flooding,  that  I  might  be  instantly  apprized  of  it.  17th,  A.  M. 
The  patient  was  found  free  from  fever,  and  almost  free  from  dis- 
charge ;  she  continued  so  until  about  5  o'clock,  P.  M.,  when  the 
whole  scene,  as  mentioned  before,  was  renewed ;  she  was  again 
bled;  subjected  to  the  application  of  the  ice:  and  the  laudanum 
was  repeated  for  the  same  reasons  as  yesterday.  18th,  A.  M., 
8  o'clock,  I  was  called  suddenly  to  my  patient,  as  she  again  had 
a  return  of  fever,  with  hemorrhage:  she  was  again  bled,  &c. 

In  this  manner  did  matters  proceed  for  several  days;  it  was 
now  found,  that  the  arterial  exacerbations  observed  no  regular 
period;  but  whenever  they  did  occur,  there  was  uniformly  a  re- 
turn of  the  flooding;  and  would  continue  during  this  state  of  ex- 
citement. With  a  view  to  interrupt  this  condition,  or  to  abridge 
it  as  much  as  possible,  I  placed  a  young  gentleman  at  the  patient's 
bed-side,  with  orders  to  bleed  her  the  moment  he  perceived  an  in- 
crease-of  pulse ;  this  was  accordingly  done;  and  from  each  bleed- 
21 


322  Vt  UTERINE   HEMORRHAGE. 

ing  decided  advantage  was  discovered.  The  loss  of  five  or  six 
ounces  of  blood  was  sure  to  put  a  stop  to  the  uterine  discharge, 
in  the  course  of  a  few  minutes ;  and  sometimes  would  prevent  its 
appearance,  when  it  could  be  very  promptly  used.  By  proceed- 
ing in  this  manner  until  the  23d,  the  patient  was  entirely  freed 
from  this  distressing  complaint.  She  was  bled  seventeen  times ; 
and  lost,  by  computation,  one  hundred  and  ten  ounces  of  blood 
in  the  course  of  seven  days.  She  gradually  gathered  strength, 
and  was  safely  delivered  at  the  proper  time. 

The  acetate  of  lead  should  now  be  given,  in  doses  and  frequen- 
cy proportionate  to  the  extent  of  the  discharge.  From  two  to 
three  grains  may  be  given,  guarded  with  opium,  every  half  hour, 
or  less  frequently,  as  circumstances  may  direct ;  or  in  case  the 
stomach  be  irritable,  a  very  efficient  mode  of  exhibiting  it  is,  per 
anum — twenty  or  thirty  grains  may  be  dissolved  in  a  gill  of  wa- 
ter, to  which  must  be  added  a  drachm  of  laudanum,  and  this  be 
repeated,  pro  re  nata ;  or  we  may  give  the  extract  of  rhatany 
with  great  advantage,  in  the  manner  already  recommended  at 
p.  143,  only  the  quantity  should  be  repeated  every  hour  or  two. 

If  pain  attend,  opium  should  be  given  until  a  decided  impres- 
sion be  made  upon  the  uterine  contractions ;  or  until  its  exhibi- 
tion appears  to  be  totally  unavailing.  Should  the  discharge  be 
profuse,  the  application  of  equal  parts  of  cold  vinegar,  and  spirit 
of  any  kind  may  be  applied  to  the  region  of  the  pubes ;  or  what 
is  still  better,  a  large  bladder,  two-thirds  filled  with  ice  and  wa- 
ter :  the  tampon  should  be  introduced  without  farther  delay. 

For  the  discharge  from  the  uterus,  when  very  profuse,  will 
not  always  yield  to  these  remedies ;  and  if  it  do  not,  it  will  very 
soon  become  highly  alarming.  To  save  even  a  few  ounces  of 
blood,  is  always  desirable ;  and  sometimes  it  is  highly  important ; 
should  the  means  just  recommended  fail  in  moderating,  or  stop- 
ping the  threatened  symptoms,  no  time  should  be  lost  in  employ- 
ing the  tampon.  The  best,  I  believe,  is  a  piece  of  fine  sponge 
of  sufficient  size  to  fill  the  vagina.  It  should  have  pretty  sharp 
vinegar  squeezed  from  it  several  times,  with  a  view  to  clean 
it,  and  to  have  it  imbued  with  this  acid ;  it  may  then  be  intro- 
duced into  the  vagina,  and  suifered  to  remain  until  its  object  is 
answered. 

Previously,  however,  to  the  introduction  of  the  sponge,  it  will 
be  well  to  examine  the  state  of  the  neck  of  the  uterus  and  the 
os  tincse ;  their  condition  will  very  much  govern  our  decision 
and  prognostics.  Should  the  one  be  found  entirely  closed,  and 
the  other  of  its  original  shape,  we  may,  notwithstanding  the  pro- 
fuseness  of  the  discharge,  and  even  the  presence  of  pain,  still  en- 
tertain a  rational  hope  of  preserving  the  ovum ;  but  if,  on  the  con- 
trary, the  form  of  the  neck  be  altered,  and  the  mouth  opened,  we 
are  pretty  certain  it  will  sooner  or  later  be  cast  off.  But  neither 


UTERINE    HEMORRHAGE.  323 

of  these  conditions  is  to  affect  our  conduct,  as  regards  the  hemor- 
rhage ;  for  this  is  to  be  stanched,  though  we  are  certain  the  em- 
bryo will  be  lost. 

Much  error  is  sometimes  committed,  under  an  impression  that 
the  ovum  must  be  expelled;  and  that  nothing  can  be  done  advan- 
tageously for  the  woman,  until  this  be  effected.  I  have  known 
a  hemorrhage  suffered  to  continue,  almost  to  the  exhaustion  of 
the  patient,  because  pain  was  considered  essential  to  the  throwing 
off  the  ovum,  though  on  each  return  of  it  a  large  coagulum  has 
been  expelled ;  or  the  discharge  has  been  augmented  by  injudi- 
cious manual  attempts  to  aid  the  expulsion  of  the  ovum.  Both 
of  these  mistaken  methods  cannot  be  too  severely  reprehended — 
one  for  blameable  supineness;  and  the  other,  for  rash  inter- 
ference. 

Whatever  may  be  the  rapidity  of  the  discharge  in  such  cases, 
it  is  ever  under  command,  so  far  as  my  experience  will  warrant 
the  assertion,  by  the  use  of  the  tampon.  This  should  be  instantly 
resorted  to  ;  and  its  effects  will  be  quickly  perceived.1 

I  deprecate  with  much  earnestness,  frequent  and  unnecessary 
touching.  This  is  not  only  injurious,  by  fatiguing  the  patient,  but 
by  removing  coagula,  that  may  be  important  to  the  stopping  of 
the  hemorrhage.  This  should,  therefore,  always  bo  avoided ; 
except  at  such  times  as  it  may  become  necessary  to  ascertain 
whether  the  mouth  of  the  uterus  be  yielding  to  the  influence  of 
pain.  It  therefore  can  only  be  necessary  in  such  cases  as  are, 
or  have  been  accompanied  by  uterine  contractions. 

I  also  must  seriously  forbid  all  attempts  to  remove  the  ovum 
so  long  as  the  greater  part  of  its  bulk  is  within  the  cavity  of  the 
womb;  lest  its  covering  be  broken,  and  the  liquor  amnii  evacu- 
ated. We  must  let  no  false  theory  get  the  better  of  multiplied 
experience :  all  the  latter  goes  to  prove  the  impropriety  of  such  a 
procedure ;  for  it  is  agreed  by  the  most  enlightened  upon  this 
subject,  that  it  is  mischievous  to  effect  it,  and  unfortunate,  when 
it  spontaneously  happens.  The  reason  is  obvious.  The  embryo 
is  expelled,  but  its  involucrum  is  retained;  in  consequence  of 
which,  the  flooding  is  perpetuated,  and  much  pain,  and  other  in- 
convenience, if  not  danger,  are  experienced,  before  it  is  thrown 
off  from  the  uterus.  I  must  therefore  repeat  it  as  a  rule,  that 
the  ovum  is  never  to  be  pierced  before  the  commencement  of  the 
fifth  month,2  unless  the  flooding  js  very  profuse,  the  pains  very 
urgent,  and  the  os  uteri  pretty  well  opened. 

1  Dr.  Meigs  informed  me,  however,  of  a  case  that  fell  under  his  notice,  in  which 
the  discharge  continued  in  an  alarming  quantity,  though  a  tampon  had  been  em- 
ployed. In  such  a  case  it  might  be  well  to  make  a  piece  of  sponge  occupy  the 
os  externum  completely,  and  its  escape  prevented  by  continued  pressure  against 
it  with  the  hand. 

*  Burton,  and  some  others,  advise  the  rupturing  of  the  ovum  even  at  the  second 
month— than  this,  nothing  can  be  less  conformable  to  either  souud  itii»oiuiig  or 
good  practice. 


324  UTERINE   HEMORRHAGE. 

In  this  advice  I  depart  from  the  very  high  authority  of  Baude- 
locque,  with  whom  it  is  not  very  safe  to  differ:  he  recommends 
this  to  be  done  always  after  the  third  month;  provided  the  mem- 
branes do  not  tear  of  themselves.  But  very  ample  experience 
has  convinced  me,  that  it  is  safer  to  preserve  them  so  long  as  the 
os  uteri  remains  closed,  be  the  pains  ever  so  frequent  or  power- 
ful, or  the  flooding  ever  so  profuse ;  for  the  one  may  be  diminished 
by  opium,  and  the  other  arrested  by  the  tampon.  And  if  no  pain 
attend,  it  almost  becomes  criminal  to  do  so;  since  the  ovum  may, 
by  the  use  of  the  tampon  and  the  other  remedies  above  suggested, 
be  preserved. 

I  have  ever  found,  in  such  cases,  that  much  effort  is  required 
to  expel  the  secundines ;  nor  will  we  be  much  surprised  at  this, 
when  we  recollect  the  strong  disposition  the  mouth  of  the  uterus 
has  to  close  itself  at  this  period  of  utero-gestation.  Indeed,  I  have 
repeatedly  witnessed  most  alarming  floodings  from  the  placenta 
engaging  in  the  mouth  of  the  uterus,  and  am  certain  that  they 
arose  from  the  presence  of  the  placenta,  as  the  discharge  always 
ceased  so  soon  as  this  mass  was  removed. 

When  the  hemorrhage  is  contained  in  this  manner,  the  pla- 
centa should  be  removed  as  quickly  as  possible ;  but  this  is  the 
difficulty.  At  the  early  periods  of  pregnancy,  (those  compre- 
hended within  the  first  five  months,)  the  uterine  cavity  is  too 
small  to  admit  the  hand,  or  even  a  couple  of  fingers;  indeed, 
sometimes,  not  even  one;  therefore,  any  attempt  to  deliver  it  by 
the  hand  alone,  must  almost  always  fail.  If  this  mass  be  entirely 
within  the  uterus,  or  even  nearly  so,  the  os  uteri  will  be  found 
most  generally,  so  much  closed,  even  at  the  fifth  month,  as  to 
prevent  the  introduction  of  the  finger  to  hook  down  the  placenta : 
and  as  we  descend  from  this  to  the  second  month,  or  lower,  it 
will  certainly  be  so  small,  as  to  prevent  the  intromission  of  even 
one. 

Whenever  this  is  attempted,  (especially  by  the  experienced,) 
it  is  almost  sure  to  end  in  disappointment.  Sometimes  a  portion 
of  the  placenta  is  felt  without  the  os  tincge ;  and  should  its  greater 
bulk  be  so  situated,  we  can  sometimes  remove  the  whole,  by 
pressing  it  between  two  fingers,  and  withdrawing  it;  and  thus 
put  a  stop  to  the  discharge;  but  it  is  rare  that  we  are  so  fortu- 
nate.1 

In  such  cases,  I  have  employed,  with  the  most  entire  success, 
a  small  wire  crotchet.  This  instrument  is  very  simple  in  its  con- 
struction, as  well  as  in  its  mode  of  action.2 

'  From  some  late  experience,  I  am  induced  to  believe,  that  the  ergot,  if  given 
at  this  time,  will  often  supersede  the  necessity  of  the  "  crotchet."  It  must,  how- 
ever, be  borne  in  mind,  that  it  is  only  in  cases  in  which  we  cannot  command  the 
removal  of  the  placenta  by  the  fingers — that  is,  where  this  mass  continues  to  oc- 
cupy the  uterine  cavity,  or  but  very  little  protruded  through  the  os  tincse. 

1  The  drawing  I  have  given  of  this  instrument  is  upon  a  reduced  scale;  the 
reduction  is  one-third.  I  consider  this  much  more  simple  than  the  pince  a  faux 


UTEKINE   HEMORRHAGE. 

The  manner  of  using  it  is  as  follows: — The  forefinger  of  the 
right  hand  is  to  be  placed  within,  or  at  the  edge  of  the  os  tincse ; 
with  the  left,  the  hooked  extremity  of  the  crotchet  is  conducted 
along  the  finger,  until  it  be  within  the  uterus ;  it  is  now  to  be 
gently  carried  up  to  the  fundus,  and  then  slowly  drawn  down- 
wards, which  makes  its  curved  point  fix  in  the  placenta :  when 
thus  engaged,  it  is  gradually  drawn  downwards,  and  the  pla- 
centa with  it.  The  discharge  instantly  ceased,  in  every  case  in 
which  I  have  used  it.  In  all  the  instances  to  which  I  here  refer, 
I  am  persuaded  the  women's  lives  were  saved.  In  illustration 
of  what  I  have  just  urged,  I  will  relate  one  of  the  cases  of  the 
several  that  have  fallen  immediately  within  my  notice.  I  was 

called  to  Mrs.  H ,  on  the  third  of  August,  1807 ;  she  was 

at  the  third  month  of  pregnancy,  and  was  flooding  violently; 
pains  were  frequent  and  severe;  large  doses  of  the  acetate  of 
lead  and  opium  were  ordered,  together  with  cold  applications 
externally — the  mouth  of  the  uterus  was  a  little  open ;  the  ovum 
protruding;  quiet,  cold  drinks,  &e.  were  ordered.  I  now  left 
my  patient,  and  returned  at  twelve  o'clock,  three  hours  after  the 
first  visit — the  hemorrhage  not  abated ;  pains  increased ;  the  os 
tincaj  more  dilated,  and  the  ovum  more  tangible.  At  three 
o'clock,  P.  M.,  the  ovum  opened  spontaneously,  and  the  embryo 
escaped — flooding  violent;  pains  trifling;  syncopes  frequeht; 
pulse  very  small  and  quick ;  the  placenta  in  part  engaged  in  the 
os  uteri — a  stimulating  injection  was  ordered,  with  a  hope  it 
would  bring  away  the  placenta.  Four  o'clock,  P.  M.,  the  injec- 
tion failed  in  the  object  for  which  it  was  given ;  hemorrhage 
continues;  syncopes  frequent;  pulse  scarcely  perceptible.  The 
placenta  was  now  removed  by  the  wire  crotchet;  the  flooding 
ceased  instantly;  the  subsequent  symptoms  were  very  mild. 

Sometimes,  when  the  ovum  has  opened,  and  the  embryo  es- 
caped, but  has  left  its  involucrum  behind,  the  hemorrhage  may 
not  be  violent,  but  may  be  of  long  continuance;  at  least  it  will 
be  as  long  as  this  mass  remains.  In  such  cases  where  time  is 
not  so  precious  to  the  safety  of  the  woman,  I  have,  in  several 
instances  of  this  kind,  administered  the  ergot  in  twenty-grain 
doses,  with  very  decided  and  prompt  advantage. 

The  peculiarity  of  this  period  consists  in  the  ovum  not  having 
the  transparent  membranes  formed;  and  the  practice  founded 
upon  this,  as  a  general  rule,  is  never  to  break  the  wails  of  it. 

germe,  as  proposed  by  Levret,  and  recommended  by  Lerouxand  Baudelocque;  or 
that  of  Burton,  for  the  same  purpose. 


326  UTERINE   HEMORRHAGE. 


-  Second  Period. 

This  comprises  all  the  time  from  the  fourth  and  a-half,  or  the 
fifth  month,  to  the  entire  completion  of  utero-gestation. 

The  woman  is  liable  to  hemorrhage  during  any  part  of  this 
period,  by  the  action  of  any  of  the  remote  causes  already  enume- 
rated ;  and  in  proportion  to  the  advancement  of  pregnancy,  will 
be  the  risk  from  flooding,  as  the  quantity  of  blood  thrown  out  in 
a  given  time  is,  cseteris  paribus,  greater  and  more  difficult  to 
arrest.  Therefore,  when  a  woman  is  attacked  with  a  discharge 
of  this  kind,  however  moderate  it  may  be  in  the  commencement, 
we  have  no  security  against  its  increase,  at  any  after-moment — 
she  is  to  be  carefully  watched,  and  most  fully  advised.  We 
should  insist  upon  compliance  with  the  rules  directed  for  the  first 
period,  and  we  must  employ  the  remedies  already  proposed,  as 
early  as  the  nature  of  the  case  may  require. 

I  have  already  intimated,  that  a  hemorrhage  from  the  uterus 
during  pregnancy,  can  only  happen  from  a  portion  of  the  pla- 
centa being  detached.  It  will  follow  that  the  issue  of  blood  will 
be  in  proportion  to  the  extent  of  surface  so  exposed ;  to  the  ad- 
vancement of  pregnancy  and  the  force  of  the  circulation.  Now 
as  the  advancement  of  pregnancy  is  greater  in  this,  our  second 
division,  than  in  the  first,  the  chances  for  a  more  profuse  dis- 
charge of  blood  are  increased  in  an  equal  proportion :  hence  it 
is  agreed  upon  all  hands,  that  the  risk  the  woman  runs  is  very 
great;  so  great,  indeed,  sometimes,  as  to  be  very  speedily  fatal ; 
since  we  can  have  no  influence  over  the  extent  of  separation  of 
the  placenta,  nor  always  have  control  over  the  force  of  arterial 
action. 

The  indications,  however,  are  precisely  the  same  as  for  the 
"first  period;"  but  their  fulfilment  is  not  always  effected  after 
the  same  manner. 

It  is  my  practice,  in  cases  of  a  threatened  flooding,  during 
pregnancy,  or  when  from  the  rapidity  of  the  discharge  the 
woman's  strength  would  be  quickly  exhausted,  to  use,  in  addition 
to  the  means  just  mentioned,  the  tampon.  I  have  already  said, 
I  have  found  fine  sponge  the  best;  but  where  this  cannot  be 
procured,  fine  flax,  or  very  well  picked  tow,  or  old  linen,  may 
be  substituted. 

When  the  latter  substances  are  chosen,  they  should  be  used  in 
portions  of  moderate  size,  and  well  moistened  with  sweet  oil, 
or  melted  lard — they  should  be  introduced  one  by  one,  until  the 
vagina  is  completely  filled;  the  whole  may  be  secured  by  a  com- 
press and  T  bandage.  This  latter  precaution  is  not  necessary 
when  a  sponge  is  used,  if  the  piece  be  of  proper  size.  From  its 
compressibility,  it  is  introduced  without  the  least  inconvenience, 


UTERINE    HEMORRHAGE.  327 

if  previously  prepared  as  directed ;  and  I  believe  it  promotes 
coagulation  quicker  than  any  other  substance,  from  its  numerous 
cells  giving  speedy  passage  to  the  finer  parts  of  the  blood.  It 
almost  instantly  puts  a  stop  to  the  hemorrhage ;  and  in  some 
instances,  I  believe  I  was  entirely  indebted  to  it  for  the  preser- 
vation of  the  lives  of  my  patients. 

Some  object  to  the  employment  of  the  tampon ;  they  say  there 
is  danger  of  local  inflammation  from  the  use  of  vinegar :  but  ex- 
perience has  proved  it  to  be  futile. 

The  mode  of  action  of  the  tampon  in  stopping  hemorrhage  is 
precisely  the  one  nature  employs,  when  she  alone  effects  this  end. 
A  coagulum  is  formed  from  the  tampon  to  the  mouth  of  the 
bleeding  vessels,  and  thus  puts  a  stop  to,  or  very  much  dimi- 
nishes, the  farther  issue  of  blood.  It  would  seem,  from  all  we 
know  upon  this  subject,  that  there  is  a  strong  disposition  in  the 
cut  or  divided  extremity  of  a  blood  vessel  when  at  rest,  or  nearly 
at  rest,  to  form  a  coagulum  within  itself,  for  the  purpose  of  put- 
ting an  end  to  the  farther  issue  of  blood;  hence,  the  importance 
of  coagula  at  the  mouths  of  the  bleeding  arteries ;  the  formation 
of  which  is  the  first  step  towards  spontaneous  suppression. 
Puzos,1  many  years  since,  had  pretty  nearly  the  same  notion 
upon  this  subject ;  he  said,  that  the  coagula  acted  as  corks  to 
the  mouths  of  the  bleeding  vessels. 

The  internal  remedies  for  the  suppression  of  uterine  hemor- 
rhage, when  successful,  must  act  by  disposing  the  blood  to  co- 
agulate more  speedily ;  or  immediately,  upon  the  open  extremi- 
ties of  the  bleeding  vessels,  so  as  to  induce  them  to  contract. 
Hence,  the  almost  universal  employment  of  that  class  of  medi- 
cines called  astringents.  Leroux,2  however,  forbids  them  in 
uterine  hemorrhage,  after  delivery ;  but  he  does  this  upon  a  wrong 
principle.  He  says,  "Dans  1'hsemorrhagie  uterine  violente  qui 
succ6de  al  1'accouchment,  ils  ne  peuvent  etre  d'aucune  utilite. 
Pour  s'en  convaincre,  il  suffit  de  se  repr6senter  la  route  qu'ils 
sont  obliges,  de  suivre  avant  de  parvenir  ou  lieu  aii  leur  pour- 
rait  etre  utile,  le  temps  qu'ils  mettent  si  parcourir  ce  trajet,  et 
les  changemens  qu'ils  6prouvent  avant  d'y  arriver." 

In  like  manner,  from  their  mode  of  action,  Leake3  objects  to 
the  use  of  astringents  or  styptics  in  this  complaint ;  and  upon  no 
better  ground,  I  think,  than  Leroux ;  for  I  know  that  certain  of 

1  "Ces  sages  precautions  ont  suspendu  souvent,  et  quelquefois  ont  fait  cesser 
des  pertes  de  sang  accompagnfees  de  petits  caillots ;  non  pas  en  soudant,  pour 
ainsi  dire,  a  1'interieur  de  la  matrice  Ie3  portions  du  placenta  separees,  mais  en 
donnant  le  temps  au  sang  arrete  a  1'embouchure  dps  vaisseaux  de'sy  cailleboter, 
et  d'y  former  de  petis  bouchons  moules  sur  leur  diametre  capableg  d'arreter  le 
sang."  (Mem.  de  1'Acad.  torn.  i.  p.  211.) 

'  Observations,  &c.  p.  209. 

»  On  Child-bed  Fever,  vol.  ii,  p.  301. 


328  UTERINE    HEMORRHAGE. 

them,  as  the  sugar  of  lead,  (especially.)  produces  sometimes  the 
most  decided  and  prompt  effects,  let  its  mode  of  action  be  what 
it  may. 

In  many  instances,  it  exerts  a  control  over  the  bleeding  ves- 
sels, as  sudden  as  the  ergot  does  upon  the  uterine  fibre ;  and,  from 
the  extent  and  certainty  of  this  action,  we  might  be  tempted, 
without  doing  much  violence  to  the  delicacy  of  medical  specula- 
tion, to  call  its  action  specific.  In  a  word,  we  may  justly  ques- 
tion, whether  any  internal  remedy  can  be  successful  in  uterine 
hemorrhage,  which  does  not  exert  an  action  somewhat  specific. 

But  neither  internal  remedies  nor  external  applications  should 
be  exclusively  relied  upon,  longer  than  is  decidedly  consistent 
with  the  safety  of  the  patient ;  for  neither  astringents  of  any 
kind,  nor  the  tampon,  can  be  availing  in  all  cases ;  and  when  they 
fail,  there  is  but  one  resource,  namely  delivery;  the  considera- 
tion of  which  brings  us  to  the  other  modes  employed  by  a  large 
class  of  practitioners,  for  stopping  uterine  hemorrhage ;  namely, 
those  who  consider  delivery  the  only  resource. 

SECT.  V. — Delivery  considered  as  a  Mode  of  arresting 
(t  Hemorrhage. 

From  the  time  of  Mauriceau  and  Dionis  to  the  present  mo- 
ment, the  number  belonging  to  this  class  is  very  considerable ; 
and  if  numbers  merely  were  to  be  considered,  the  weight  of  evi- 
dence would  be  in  favour  of  their  practice.  The  want  of  proper 
knowledge  in  treating  uterine  hemorrhage  by  other  means ;  the 
fatal  rapidity  of  its  termination  sometimes,  where  rupturing  of 
the  membranes,  or  delivery,  was  not  performed,  or  where  a  feeble 
plan  had  been  pursued :  the  occasional  success  of  delivery,  toge- 
ther with  the  strong  probability  of  uterine  contraction  after  this 
organ  is  emptied,  and  the  influence  of  this  contraction  in  arrest- 
ing the  bleeding,  has  but  too  easily,  and  too  generally,  found  ad- 
vocates for  its  almost  exclusive  employment.  Thus,  La  Motte1 
thought  it  impossible  to  restrain  hemorrhage,  when  the  placenta 
was  detached  in  part  or  entirely,  but  by  the  extraction  of  this 
mass;  Dionis  declared  we  should  not  defer  the  delivery  of  the 
foetus,  if  blood  in  great  quantity  and  without  interruption  escaped 
from  the  uterus.2  Mesnard  advised  delivery,  if  there  was  a  flood- 
ing sufficient  to  cause  fainting;3  and  Heister4  and  Puzos'  were 
of  the  same  opinion,  &c.,  &c.;  for  it  would  be  easy  to  multiply 
authorities,  to  considerable  extent,  to  the  same  end. 

1  Traite  des  Accouchemens,  Obs.  216.  •  Des  Operations,  p.  249. 

1  Pasta,  p.  170.  «  Surgery,  part  ii.  p.  257. 

1  Mem.  de  1'Acad.  vol.  i.  p.  224. 


UTERINE  HEMORRHAGE. 

The  advocates  for  delivery,  as  the  only  means  of  arresting  he- 
morrhage, may  be  divided  into  two  classes ;  first,  those  who  paid 
no  regard  to  the  condition  of  the  uterus  when  the  operation  was 
undertaken.  The  second,  those  who  evacuated  the  liquor  amnii 
previously  to  delivery,  with  a  view  to  promote  the  contraction  of 
the  uterus,  and  hy  this  means  put  a  stop  to  the  flooding;  the 
latter  may  be  subdivided  into  three :  1st.  Those  who  did  not 
regard  the  situation  of  the  os  tincae,  when  they  ruptured  the 
membranes ;  and  if  this  operation  did  not  immediately  succeed, 
entered  the  uterus  with  the  hand,  by  forced  means,  and  imme- 
diately effected  the  delivery.  2d.  Those  who,  having  torn  the 
membranes  and  gained  the  feet,  were  contented  to  bring  them  to 
the  orifice  of  the  uterus,  and  then  trust  to  the  natural  efforts  to 
perform  the  delivery.  3d.  Those  who  never  pierced  the  mem- 
branes but  when  the  mouth  of  the  uterus  was  either  dilated  or 
dilatable;  and  who,  after  rupturing  them,  permitted  them  to 
escape  gradually,  and  finish  the  delivery  slowly,  or  waited  for 
the  efforts  of  nature. 

From  the  improvements  which  midwifery  has  received  within 
the  last  fifty  years,  I  should  not  have  expected  to  meet  with  an 
advocate  for  indiscriminate  delivery,  at  the  present  day ;  yet  in 
Meygrier  we  find  that  advocate.  That  the  most  mischievous 
consequences  have  followed  the  practice  of  those  who  compose 
the  first  class,1  we  have  the  authority  of  Pasta,2  who  deprecates 
the  practice  as  both  cruel  and  dangerous ;  of  Kok,3  who  says  he 
has  seen  it  followed  by  inflammation  of  the  womb;  of  Leroux,4 
who  declares  it  to  be  dangerous  to  both  mother  and  child ;  of 
Baudelocque,3  who  insists  that  nothing  can  justify  the  accou- 
cheur, who  persists  to  deliver  while  the  neck  of  the  uterus  retains 
its  natural  thickness  and  firmness.  And  I  may  add  my  own  ex- 
perience, as  I  once  witnessed  death  as  the  consequence  of  such 
a  proceeding. 

The  method  pursued  by  those  of  the  first  division  of  the  se- 
cond class,  is  not  free  from  serious  inconveniences,  and  is,  per- 
haps, scarcely  inferior  to  the  first,  as  the  same  violence  must  al- 
most necessarily  be  committed.  The  plan  of  the  second  division 
of  the  second  class,  (which  I  shall,  in  conformity  with  custom, 
call  Puzos'  method,)  is  far  from  being  the  one  most  conformable 
to  the  principles  of  the  art :  since,  in  its  performance,  great  vio- 
lence is  frequently  obliged  to  be  resorted  to. 

1  Among  the  first  class,  may  be  reckoned  all  the  accoucheurs  prior  to  the  time 
of  Mauriceau.  To  the  second  class,  and  the  first  division  of  that  class,  belong 
Mauriceau,  Dionis,  La  Motte,  Deventer,  &c.  &c.  To  the  second  division,  we 
may  place  Puzos,  Smellie,  Delourie,  &c.  &c.  And  to  the  third,  we  have  Lerouz, 
and  most  of  the  late  writers  upon  midwifery. 

a  Vol.  i.  p.  132.  '  Pasta,  p.  276. 

4P.  241.  •  Vol.  ii.  p.  90. 


330  UTERINE   HEMORRHAGE. 

The  objections  to  this  scheme  are,  1st,  that  every  flooding 
during  pregnancy  is  not  necessarily  followed  by  delivery;  but 
if  we  adopt  this  method,  it  must,  within  a  short  period,  take  place, 
and  this,  perhaps,  to  the  destruction  of  the  foetus. 

2d.  Because  the  mouth  of  the  uterus  may  be  so  placed  as  to 
render  this  operation  very  difficult,  if  not  impossible;  especially 
when  the  uterine  orifice  is  still  very  thick  and  rigid ;  for  Puzos1 
himself  confesses  he  was  an  hour  or  more  before  he  could  pierce 
the  membranes ;  and  this  was  a  loss  of  most  precious  time  to  the 
patient,  as  the  flooding  still  went  on,  and  he  began  to  despair  of 
the  success  of  his  method,  from  the  excessive  loss  of  blood,  and 
was  fearful  he  should  be  obliged  to  have  recourse  to  forced  de- 
livery. 

3d.  That  the  hemorrhage  does  not  always  cease  after  the  rup- 
ture of  the  membranes ;  but,  on  the  contrary,  sometimes  becomes 
more  violent  at  this  operation. 

4th.  That  the  presentation  of  the  child,  if  it  be  preternatural, 
and  the  presence  of  the  placenta  over  the  mouth  of  the  uterus, 
will  render  this  method  ineligible. 

5th.  It  is  sometimes  impossible  to  make  a  forced  delivery ;  es- 
pecially from  the  fifth  to  the  sixth  and  a  half  month;  of  this  La 
Motte2  gives  on«  example,  and  Smellie3  another — and  I  once 
saw  a  similar  failure.  And,  above  all,  they  have  not  pointed  out 
any  alternative  when  this  plan  shall  have  failed. 

It  is  only  upon  the  method  of  those  who  compose  the  third  divi- 
sion of  the  second  class,  or  those  who  never  pierce  the  mem- 
branes but  when  the  os  uteri  is  dilated  or  dilatable,  that  we  can 
safely  place  reliance,  in  cases  of  severe  flooding. 

It  may  be  asked,  what  are  we  to  do  in  cases  of  profuse  he- 
morrhage, at  any  period  from  the  fifth  month  to  the  full  time, 
when  the  discharge  threatens  the  life  of  the  patient,  and  when 
the  os  uteri  is  closed  and  rigid?  Are  we  supinely  to  witness 
her  death,  rather  than  employ  some  violence  to  relieve  her  ? 
Certainly  not.  If  there  really  were  no  other  remedy,  forced  deli- 
very, with  all  its  disastrous  consequences,  might  be  justifiable ; 
but  as  we  have  the  power  of  plugging  the  vagina,  and  prevent- 
ing the  farther  issue  of  blood,  we  should  have  immediate  recourse 
to  it:  and  this  plan,  so  far  as  I  have  witnessed,  has  not  failed; 
and  this  experience  is  so  supported  by  that  of  Leroux,  as  to 
entitle  it  to  entire  confidence.  By  this  means,  time  is  permitted 
to  the  natural  agents  of  delivery  for  the  performance  of  their 
duties;  and  this  is  done,  for  the  most  part,  with  both  certainty 
and  success. 

The  importance  of  the  tampon  is,  perhaps,  never  so  clearly 

'Mem.  sur.  les  Pertes,  &c.  p.  336.  "Obs.  452. 

2  Collect.  33,  No.  «,  Ob.  1. 


UTERINE   HEMORRHAGE.  331 

demonstrated,  as  when  it  is  employed  in  cases  where  the  flooding 
has  proceeded  to  almost  complete  exhaustion,  and  where  every 
ounce  of  blood  is  of  immense  value.  In  such  cases,  (before  de- 
livery,) I  have  seen  it  arrest  a  profuse  flow  in  almost  a  moment, 
and  where  the  farther  loss  of*  a  few  ounces  must  have  been  fol- 
lowed by  death.  Syncope,  and  even  convulsions,  have  ceased 
upon  its  application. 

Though  it  be  confessed  that  after  the  failure  of  the  remedies 
recommended  for  the  suppression  of  hemorrhage,  as  the  applica- 
tion of  the  tampon,  &c.,  there  is  but  one  means  left  in  our  pos- 
session, (namely,  delivery,)  by  which  the  flooding  can  be  arrest- 
ed, and  the  life  of  the  woman  preserved, — yet  it  may  be  asked, 
is  there  no  condition  of  the  patient,  in  which  it  would  be  im- 
proper to  attempt  this,  besides  the  rigidity  of  the  os  uteri  ?  To 
this,  I  answer,  yes, — I  would  say,  that  a  woman  reduced  to  the 
last  extremity  of  weakness,  but  with  a  suspension  of  the  dis- 
charge, should  not  be  meddled  with,  so  long  as  the  hemorrhage 
is  kept  in  check. 

But  suppose  the  same  degree  of  weakness,  with  a  continuance 
of  the  flooding,  to  exist;  should  we,  in  such  case,  attempt  delivery? 
I  have  no  hesitation  in  answering  this  in  the  affirmative : — but, 
previously  to  the  operation,  the  condition  of  the  patient  should 
be  candidly  stated  to  her  friends:  it  must  be  undisguisedly  de- 
clared to  them,  that  no  undue  calculation  should  be  made  of  the 
benefit  of  delivery;  but,  as  this  operation  offers  the  only  possible 
chance  of  relief,  it  might  be  adopted.  We  may  be  encouraged  to 
do  this,  as  it  now  and  then  happens,  that  the  woman  recovers, 
under  such  circumstances,  contrary  to  all  expectation. 

Hitherto,  I  have  said  nothing  of  opium  as  a  remedy  in  uterine 
hemorrhage ;  the  reason  is  simply  this — it  has  never  merited  the 
smallest  commendation  in  my  hands ;  for  it  has  never  been  at- 
tended with  the  slightest  success;  of  course,  I  cannot  be  of  opi- 
nion, that  it  deserves  the  encomiums  which  have  been  so  lavishly 
bestowed  upon  it  by  Dr.  Hamilton  and  others.  I  have  read,  dis- 
passionately, and  with  care,  Dr.  Stewart's  book  upon  this  subject; 
and  have  cautiously  examined  the  cases  detailed  by  him ;  but 
they  have  not  afforded  me  the  slightest  ground  to  believe  that 
the  opium  had  any  agency  in  arresting  the  floodings  for  which 
it  had  been  so  liberally  administered:  the  cessation  uniformly 
appeared  to  be  the  result  of  the  natural  powers  of  the  system  in 
general,  and  of  the  uterus  in  particular.  That  it  is  sometimes 
beneficial,  previous  to  delivery,  in  allaying  pain,  and  in  this  way 
putting  a  stop  to  farther  mischief,  I  most  freely  confess;  but  I 
cannot  yield  any  thing  more.  I  am  not  alone  in  this  respect : 
Dr.  Denman  seemed  to  entertain  the  same  opinion ;  and  Barlow 
has  advanced  similar  sentiments. 

It  may  be  proper  to  say  a  few  words  upon  the  subject  of  cold 


332  UTERINE    HEMORRHAGE. 

applications,  as  no  remedy  has  been  more  extensively  employed, 
or  more  constantly  abused.  Cold,  as  a  means  to  arrest  flooding, 
is  in  almost  universal  employment,  is  usually  one  of  the  first  re- 
sorted to,  and  the  last  that  is  abandoned — it  has  acquired  so 
much  popularity  among  the  vulgar,  as  to  render  it  unsafe  for 
the  reputation  of  the  practitioner,  who  has  omitted  it  in  his 
treatment  of  this  complaint. 

But,  though  confessedly  an  agent  of  great  power,  it  has  never- 
theless its  limits  of  usefulness ;  and  beyond  which,  it  should  never 
be  urged — for  its  efficacy  is  very  much  confined  to  its  influence 
over  the  circulating  system,  by  diminishing  its  vigour,  and  aba- 
ting its  velocity,  though  it  may  also  act  as  a  stimulant  to  the 
uterus  when  its  shock  is  first  perceived,  and  thus  induce  contrac- 
tion ;  but  its  greatest  value  seems  to  be  in  controlling  arterial 
action.  After  these  ends  are  answered,  it  is  truly  doubtful 
whether  it  should  be  farther  persevered  in;  at  least  its  utility 
is  very  much  diminished. 

I  employ  it  very  liberally ;  and  sometimes,  if  the  case  be  urgent, 
even  at  a  very  low  temperature — in  general,  the  best  mode  of 
applying  it,  is  by  a  large  bladder,  as  has  already  been  directed 
— but,  in  very  sudden  and  alarming  cases,  I  have  caused  it  to 
be  teemed  from  a  height  upon  the  abdomen ;  and  this  method  of 
using  cold,  from  its  promptness,  and  the  extent  of  its  effects,  has 
a  very  decided  preference. 

But  if  the  pulse  flag,  and  the  woman  be  much  exhausted,  I  not 
only  forbid  it,  but  have  a  warm  blanket,  or  other  warm  articles, 
to  supply  its  place.  During  the  use  of  cold  water,  &c.,  to  the 
abdomen,  warm  applications  should  be  made  to  the  feet  and  legs ; 
a  bottle  or  jug  of  warm  water,  well  corked,  is  one  of  the  best  and 
most  handy:  this  last  direction  should  never  be  omitted  when 
the  feet  and  legs  are  preternaturally  cold.  We,  also,  should  be 
particularly  careful  not  to  wet  the  bed  and  clothes  of  the  patient, 
if  it  can  be  possibly  avoided,  as  it  creates  much  inconvenience, 
by  rendering  her  situation  extremely  unpleasant,  besides  obliging 
her  to  be  disturbed,  that  dry  things  may  be  substituted. 

The  injecting  of  cold  water,  cold  alum-water,  the  solution  of 
the  acetate  of  lead,  the  introduction  of  ice  into  the  vagina,  and 
even  into  the  uterus,  &c.,  have  been  practised ;  and,  it  it  said, 
with  advantage.  The  merits  of  such  applications  must  rest  upon 
the  authority  of  those  who  recommend  them ;  for  I  confess  I 
have  no  experience  in  either  of  them ;  nor  should  I  be  tempted 
to  rely  upon  them  in  very  pressing  cases.1 

It  may  be  proper  to  observe,  in  addition  to  the  remedies  and 
modes  of  proceeding  pointed  out  in  this  division  of  our  subject, 

1  See  chap,  on  "  Unavoidable  Uterine  Hemorrhage,5'  in  the  author's  System  of 
Midwifery,  for  a  variety  of  means  lately  proposed  for  the  relief  of  hemorrhage. 


INFLAMMATION    OF    THE    UTERUS.  333 

that  in  certain  cases  of  uterine  hemorrhage,  the  forceps  are  the 
only  means  to  be  employed  or  relied  upon.  They  are  exclusively 
indicated,  1st,  Where  the  discharge  is  threatening,  and  the  labour 
well  advanced ;  but  where  the  membranes  have  been  long  rup- 
tured, and  the  uterus  is  firmly  embracing  the  body  of  the  child, 
or  the  head  does  not  advance  with  sufficient  rapidity  to  afford 
security.  2d,  Where  the  head  is  low  in  the  pelvis,  and  has 
escaped  from  the  orifice  of  the  uterus — in  this  case,  turning  must 
not  be  thought  of,  however  recent  may  have  been  the  escape  of 
the  waters;  or  however  moveable  the  head  may  be  in  the  pelvis. 
3dly,  Where  the  uterine  efforts  are  either  feeble,  or  suspended ; 
and 'where  the  os  uteri  is  sufficiently  distended,  but  where  the 
waters  have  been  long  discharged.  4thly,  Where  the  head  oc- 
cupies the  inferior  strait ;  the  orifice  of  the  uterus  sufficiently  ex- 
panded; the  waters  either  recently  or  a  long  time  expended;  but 
where  the  natural  agents  of  delivery  would  act  too  slowly  for  the 
safety  of  the  patient.1  5thly,  Where  the  natural  powers  are  in- 
competent to  the  sufficiently  speedy  delivery  of  the  patient ;  owing 
either  to  the  waZ-position  of  the  head,  or  to  such  a  disparity  be- 
tween it  and  the  pelvis,  as  shall  prevent  its  timely  expulsion. 


CHAPTER  XVII. 


HTSTERITIS,  OR  INFLAMMATION  OF  THE  UTERUS. 

THERE  is  more  ambiguity,  or  at  least  a  greater  want  of  pre- 
cision, in  the  accounts  of  the  acute  diseases  which  attack  the 
puerperal  woman,  than  in  any  others  whatever.  This  does  not 
arise  from  an  absolute  necessity;  for  they  are  neither  obscure 
nor  numerous.  Those  which  attack  the  uterine  system  and  its 
dependencies,  have  chiefly  created  the  confusion;  and  this  has 
mainly  arisen  from  an  overweening  desire  for  great  accuracy  of 
distinction,  without  a  corresponding  power  to  give  the  signs  by 
which  each  should  be  ascertained.  Or  in  some  instances,  from 
a  blameable  generalization,  making  every  febrile  affection  puer- 
peral fever. 

Thus,  the  disease  now  under  consideration  has  almost  always 
been  confounded  with  puerperal  fever;  and  the  latter  as  fre- 
quently blended  with  the  former:  this  has  arisen  almost  entirely 

1  From  late  experience,  we  have  reason  to  believe  that  the  secale  cornutum 
may,  occasionally,  supersede  the  necessity  of  the  forceps  in  this  case :  it  should, 
at  all  events,  be  tried. 


334  INFLAMMATION    OF    THE    UTERUS. 

from  not  allowing  that  puerperal  fever  is  an  inflammation  of 
some  one  portion  or  the  whole  of  the  peritoneum;  and  in  not 
thinking,  or  believing,  that  the  proper  substance  of  the  uterus 
can  be  inflamed  without  necessarily  involving  this  membrane ; 
though  the  latter  may  become  so  secondarily.  On  this  account 
it  will  be  proper  to  divide  hysteritis  into  two  species;  the  first  we 
shall  call  the  simple  or  pure ;  the  second,  the  mixed  or  accidental 
inflammation  of  the  peritoneum,  or  superadded  puerperal  fever. 
The  first  we  shall  define  to  be  an  inflammation  of  all  or  any 
portion  of  the  proper  substance  of  the  uterus,  except  its  peritoneal 
covering.  The  second  where  the  latter  is  implicated  with  the 
former.  It  has  been  rendered  highly  probable,  from  the  late  ob- 
servations of  Mr.  Dance,  and  M.  Tonnelle,  that  in  hysteritis  it 
is  the  veins  of  the  uterus  that  are  inflamed,  and  constituting  a 
genuine  phlebitis.  Dr.  Conquest  says,  "  The  substance  of  the 
uterus  is  sometimes  infiltrated  with  pus,  and  becomes  livid  and 
spongy,  or  it  may  contain  small  abscesses ;  and  the  uterine  veins, 
particularly  those  containing  blood  from  the  spermatic  arteries, 
may  be  inflamed,  and  contain  coagula  or  pus."  Obs.  on  Puerp. 
Inflam.  And  M.  Tonnelle  says  if  proper  care  be  not  taken  in 
dissection,  it  will  be  supposed  abscesses  of  the  proper  tissue  exist, 
when  the  vessels  are  only  affected. 


SECT.  I. — SPECIES  1. — Causes. 

The  causes  which  may  produce  inflammation  of  the  uterus 
are  all  or  any  of  the  violences  to  which  this  organ  may  be  ex- 
posed in  the  exercise  of  its  functional  powers,  during  the  expul- 
sion of  the  child ;  from  those  to  which  extrinsic  aid  may  give  rise, 
when  its  powers  have  been  insufficient  for  the  purposes  of  deli- 
very ;  from  those  which  may  arise  from  the  artificial  delivery  of 
the  placenta ;  or  those  which  may  act  independently  of  either, 
but  not  readily  cognizable. 

Under  the  first  head  we  reckon,  1st,  the  long  and  reiterated 
efforts  the  uterus  is  occasionally  forced  to  make  to  overcome  the 
resistance  which  opposes  the  expulsion  of  the  child;  whether  this 
arise  from  the  rigidity  of  the  neck  of  the  uterus ;  or  of  the  ex- 
ternal soft  parts ;  the  construction  of  the  pelvis ;  or  the  size  or 
situation  of  the  child. 

2d.  To  violences  committed  in  the  use  of  instruments  of  any 
kind;  to  injuries  sustained  in  the  act  of  turning;  or  to  ill-directed 
manoeuvres  executed  on  the'  neck  of  the  uterus  in  attempting  its 
dilatation,  or  by  too  frequent  handling. 

3d.  To  lesions  of  the  internal  face  of  this  organ,  from  a  sud- 
den, rude  and  unnecessary  interference  in  the  separation  of  the 


INFLAMMATION   OF  THE   UTERUS.  335 

placenta ;  or  to  the  injuries  it  may  sustain  from  a  placenta  that 
has  been  too  adherent. 

4th.  To  those  which  may  arise  from  exposure  to  cold ;  checked 
perspiration;  some  secret  influence  of  the  air;  improper  regi- 
men, &c. 

2.  Symptoms. 

Whichever  of  the  causes  may  have  acted  with  sufficient  force 
to  produce  inflammation  of  the  uterus,  we  find  that  it  generally 
betrays  itself  within  the  first  five  or  six  days  after  delivery. 

The  woman  complains  of  a  pain  at  the  very  lower  part  of  the 
abdomen,  which  gradually  increases  or  can  easily  be  augmented 
by  pressure  made  immediately  above  the  symphysis  pubis.  It 
is  also  increased  by  any  motion  which  may  disturb  the  repose 
of  the  uterus,  as  turning  in  bed ;  sitting  up ;  passing  of  water ; 
or  going  to  stool. 

If  the  fingers  be  made  to  press  upon  the  uterus  externally,  it 
will  be  pretty  readily  distinguished  by  its  size  being  greater  than 
is  usual  at  such  a  period  after  delivery;  by  its  hardness,  (which 
is  very  resisting,)  and  by  its  unusual  tenderness. 

The  pain  which  the  woman  feels  is  constant ;  or  it  may  be  oc- 
casionally lancinating ;  but  it  is  always  greatest  when  the  uterus 
contracts  and  produces  after-pains.  From  the  after-pains  with 
which  it  is  sometimes  confounded,  it  may  be  distinguished  by  th'e 
latter  being  always  alternate ;  and  when  the  contractions  subside 
which  produce  them,  the  woman  is  altogether  free  from  pain, 
until  they  are  again  renewed. 

There  is  no  swelling  of  the  abdomen  in  the  commencement  of 
this  disease,  unless  it  arise  from  the  augmented  size  of  the  uterus 
itself;  but  which  is  never  so  great  at  the  onset  of  the  complaint 
as  to  make  it  conspicuous.  The  abdomen  does  not  participate 
in  the  slightest  degree  with  the  uterus,  in  simple  hysteritis ; 
hence  there  is  none  of  that  tenderness  which  is  witnessed  in  pe- 
ritoneal inflammation,  or  puerperal  fever. 

Sometimes  there  is  a  frequent  desire  to  make  water,  attended 
with  more  or  less  pain :  or  there  may  be  a  retention  of  urine ; 
especially  if  mechanical  aid  has  been  required  to  effect  the  deli- 
very; and  the  passing  of  water  is  accompanied  by  a  sense  of 
heat  or  burning  in  the  urethra  and  vulva. 

The  urine  is  almost  always  high-coloured ;  generally  scanty, 
and  will  deposite  a  lateritious  sediment.  In  judging  of  the  urine, 
however,  we  must  take  care  that  the  mingling  of  the  uterine  fya- 
charges  with  it  be  not  mistaken  for  the  tone  of  colour  of  the 
urine  itself. 


336  INFLAMMATION    OF    THE    UTERUS. 


.  \  3.  Constitutional  Symptoms. 

The  symptoms  which  we  have  just  enumerated  may  be  looked 
upon  as  strictly  local,  and  such  as  would  necessarily  arise  from 
an  inflamed  condition  of  the  uterus ;  but  these  symptoms  exist 
but  a  short  time  independently  of  constitutional  disturbance. 

Soon  after  pain,  &c.,  as  above  described,  is  felt,  we  find  the 
heat  of  the  body  very  much  increased,  without,  for  the  most  part, 
the  interposition  of  "chill."  The  head  becomes  painful,  the 
face  flushed,  and  very  frequently  there  is  delirium,1  if  the  fe- 
brile irritation  be  not  soon  relieved. 

The  tongue  is  white,  much  loaded,  and  Dr.  Clarke  says  dry; 
but  thip  we  have  never  witnessed  at  the  beginning  of  the  dis- 
ease. It  is  true  there  is  less  moisture  than  is  usual  in  the 
mouth,  and  the  little  fluid  there  is,  is  more  clammy  than  is  com- 
mon in  fevers  of  an  ordinary  kind.  This  creates  a  great,  and 
sometimes  almost  an  insatiable  thirst. 

The  pulse  is  full,  strong,  and  hard ;  its  frequency  is  not  very 
great ;  rarely  a  hundred.2  Dr.  Clarke  says,  from  one  hundred 
to  a  hundred  and  twenty  strokes  in  a  minute.  This  we  have 
never  seen  in  the  simple  hysteritis ;  nor  does  it  become  so,  unless 
the  disease  is  running  on  to  a  fatal  termination. 

The  stomach,  we  believe,  is  never  much  affected  in  the  begin- 
ning of  the  disease ;  certainly  never,  or  but  very  rarely,  pro- 
voked to  vomiting. 

As  the  disease  progresses,  or  rather  as  soon  as  the  constitu- 
tional symptoms  commence,  the  pain  extends  itself  to  the  back, 
and  down  the  thighs ;  and  sometimes  a  pretty  severe  one  is  felt 
beneath  the  lower  part  of  the  ribs  on  the  left  side. 

As  the  lochia  are  interrupted  to  a  greater  or  less  extent  in  in- 
flammation of  the  uterus,  it  has  been  commonly  supposed  that  the 
disease  is  produced  in  consequence  of  that  obstruction.  But,  as 
the  lochia  are  nothing  but  evacuations  of  the  blood,  with  which 
the  uterus  was  filled,  and  with  which  it  will  continue  to  be  filled, 
until  the  vessels  of  this  organ  and  their  open  orifices  contract  so 
much  as  to  refuse  to  transmit  more,  the  lochia  must  be  looked 
upon  as  a  discharge  dependent  upon  the  condition  of  these  ves- 
sels, or  rather  on  the  degree  of  contraction  of  the  uterus.  Con- 
sequently, their  being  more  or  less  abundant  must  depend  upon 
the  state  of  the  vessels  which  furnish  them ;  and  the  state  of  these 

1  It  may  be  looked  upon  as  almost  a  character  of  hysteritis,  that  delirium  al- 
most always  attends  it;  while,  in  the  unmixed  puerperal  fever,  of  peritoneal  in- 
flammation, it  rarely  occurs. 

a  This  is  another  peculiarity  in  hysteritis,  as  distinguished  from  peritonitis,  and 
serves  to  show  how  much  inflammation  of  particular  structures  influences  the  cir- 
culating system.  There  is  no  instance  of  pure  hysteritis,  so  far  as  we  have  seen, 
in  which  the  pulse  is  as  quick  as  it  is  in  puerperal  fever. 


INFLAMMATION  OF   THE   UTERUS.  337 

vessels  must  necessarily  be  influenced  by  other  portions  of  the 
uterus,  by  the  degree  of  inflammation.  Now,  the  uterus  when 
inflamed,  swells ;  and  this  swelling,  in  consequence  of  its  effect 
upon  the  extremities  of  the  exposed  vessels,  prevents  the  usual 
flow  of  the  lochia ;  and  from  which  two  effects  are  produced : 
first,  an  accumulation  of  blood  in  the  uterine  vessels,  which 
stretches  them  anew;  and  second,  an  aggravation  of  the  inflam- 
mation from  this  distention,  as  well  as  augmentation  of  pain. 

We  may  assign  another  reason,  indeed,  for  the  lochia  being 
less  abundant  at  this  time;  which  is,  the  tonic  contraction  of  the 
uterus  being  suspended ;  consequently,  one  of  the  causes  by  which 
the  lochia  are  forced  through  the  vessels  of  the  uterus  is  with- 
drawn, and  the  quantity  discharged  will  consequently  be  'ess. 
It  must,  therefore,  follow,  that  the  diminished  lochia  is  but  a  con- 
sequence of  this  condition  of  the  uterus,  and  not  the  cause  of  it. 
It  would  be  as  rational  to  say,  because  there  is  a  sparing  se- 
cretion of  urine  in  nephritis,  that  this  scarcity  is  the  cause  of  the 
inflammation  of  the  kidneys;  or  that  a  diminished  quantity  of 
bile  is  the  cause  of  the  inflammation  of  the  liver  in  hepatitis. 

It  is  true  that  the  lochial  discharge  is  highly  important  at  this 
time  to  the  uterus  itself;  since  it  unloads  its  vessels,  and  thus  pre- 
vents the  consequences  that  would  most  probably  follow  its  over- 
exertions,  as  well  as  promotes  the  tonic  contraction  of  this  organ. 
But,  as  their  existence  altogether  depends  upon  the  degree  of 
permeability  of  the  vessels  which  open  within  the  uterine  cavity, 
their  quantity  and  quality  must  necessarily  be  influenced  by  the 
condition  of  these  vessels;  therefore,  the  state  of  the  vessels  of 
the  uterus  may  influence  the  lochia,  but  the  lochia  cannot  affect 
the  vessels  of  the  uterus ;  for  they  are  not  lochia  until  discharged 
from  these  vessels. 

The  return  of  the  lochia  after  they  have  been  arrested,  how- 
ever, is  justly  considered  ad  a  favourable  sign ;  and  this  circum- 
stance  has  been  urged  »s  an  additional  argument  in  favour  of 
their  agency  in  producing  this  disease.  But  here  the  effect  is 
evidently  mistaken  for  the  cause.  The  return  of  the  lochia  is 
only  an  evidence  of  the  diminished  resistance  to  the  flow  of  blood 
at  the  extremities  of  the  uterine  vessels ;  and  this  lessened  resist- 
ance is  owing  to  the  abatement  of  the  swelling  which  had  inter- 
rupted its  flow;  and  the  reduction  of  the  swelling  is  but  a  conse- 
quence of  the  retiring  of  the  inflammation. 

Therefore,  the  lochia  being  diminished,  or  arrested,  would 
tend  to  increase  the  inflammation  that  was  the  cause  of  this  di- 
minution, or  stoppage ;  as  there  would  now  be  an  accumulation 
in  the  substance  of  the  uterus,  not  only  of  all  the  blood  sent  there 
to  supply  the  lochial  discharge,  but  also  that  which  always  at- 
tends upon  inflamed  vessels.  And,  on  the  other  hand,  when  the 
cause  which  arrested  or  diminished  the  lochia,  (namely,  inflam- 
22 


338  INFLAMMATION   OF   THE   UTERUS. 

mation,)  was  so  far  diminished  as  to  leave  the  extremities  of  the 
uterine  vessels  free,  which,  by  again  transmitting  their  contents 
to  the  cavity  of  the  uterus,  would  not  only  relieve  the  engorge- 
ment with  which  they  were  accidentally  affected,  but  tend  also 
to  relieve  the  vessels  of  the  inflamed  portion  of  this  organ;  and 
in  this  way  is  the  lochial  discharge  useful. 

In  pure  hysteritis,  the  mammse  sympathize  with  the  uterus 
much  less  than  in  peritoneal  inflammation,  or  puerperal  fever; 
for  we  must  be  permitted  to  use  them  synonymously.  (See 
Chapter  on  Puerperal  Fever.)  On  this  account  we  never  have 
an  entire  suppression  of  this  secretion,  as  in  puerperal  fever,  un- 
less the  disease  runs  an  unusually  long  course,  or  has  peritoneal 
inflammation  added,  or  combined  with  it.  Indeed,  in  a  number 
of  cases  we  have  seen  the  offices  of  the  breasts  remain  undis- 
turbed during  the  whole  continuance  of  the  disease. 

This  circumstance  is  worthy  of  notice ;  since  it  not  only  serves 
as  a  distinguishing  mark  between  the  two  species  of  hysteritis, 
but  also  proves  to  us  that  the  influence  of  the  peritoneum,  or  some 
one  portion  ol  the  genital  system,  has  a  stronger  influence  over 
the  formation  ol  milk  than  the  uterus  proper  itself.  Is  this  the 
peritoneal  coat  ot  the  uterus  ?  or  is  it  only  when  the  ovaria  be- 
come involved,  that  this  secretion  is  so  decidedly  interrupted,  or 
suspended?  We  beluve  it  to  be  the  latter. 

Does  not  this  fact  seiye  to  account  for  certain  discrepancies  in 
the  accounts  we  have  of  the  inflammation  of  the  womb,  and  of 
puerperal  fever?  In  one  nuance  the  disease  is  called  hysteritis, 
though  the  secretion  of  milk  was  interrupted;  and  in  the  other, 
denying  the  disease  to  be  "genuine"  puerperal  fever,  because 
this  secretion  was  so  little  disturbed. 

In  the  first  case  it  was  a  misnomer  to  call  the  disease  hysteritis ; 
for  so  soon  as  peritoneal  inflammation  takes  place,  the  disease  is, 
strictly  speaking,  puerperal  fever,  though  its  cause  may  have 
been  a  preceding  violent  inflammation  of  the  uterus,  as  we  shall 
see  more  particularly,  presently.  In  thcsecond  case,  the  disease 
has  been  refused  the  title  of  puerperal  fever,  because  the  mam- 
mary secretion  was  but  partially  disturbed  though  a  true  peri- 
toneal inflammation  existed. 

Thus  we  find  that  the  epidemic  fever  described  by  Dr.  Leake, 
as  it  appeared  in  the  "Westminster  lying-in  hospital,"  was  re- 
markable for  the  following  peculiarities :  first,  the  omentum  be- 
ing the  most  common  seat  of  the  inflammation ;  2d,  the  almost 
total  exemption  of  the  uterus,  and  its  appendages,  from  disease; 
3d,  the  little  disturbance  of  the  lactiferous  secretion,  as  will  appear 
from  the  following  statements. 

In  case  V.,  "the  uterus  as  well  as  the  bladder,  was  perfectly 
sound,  and  without  mark  of  inflammation,  or  rather  morbid  affec- 
tion ;  (state  of  milk  not  mentioned.)  In  this  case  "  the  omen- 


INFLAMMATION    OF    THE    UTERUS.  389 

turn  was  melted  down."  In  case  VIIL,  "the  omentum  was 
much  inflamed  ;  but  the  greater  part  of  it  was  destroyed  by  sup- 
puration." "She  had  milk  in  her  breasts  until  a  day  or  two 
before  her  death."  "  The  fundus  uteri  seemed  to  partake  of  the 
general  inflammation  which  had  attacked  the  omentum."  "  The 
lochia  was  not  defective,  neither  was  there  a  want  of  milk  till 
after  the  febrile  attack."  Case  XL,  "  the  omentum  was  suppu- 
rated, and  cop  verted  into  thick  matter."  "  The  substance  of  the 
uterus  was  sound."  "The  secretion  of  milk  was  moderate  on 
the  third  day ;"  on  the  fifth,  "her  breasts  subsided,  and  the  milk 
suddenly  disappeared."  She  died  on  the  seventh  day.  Case 
XIII.,  "  the  omentum  was  destroyed."  "  The  uterus  had  a  na- 
tural appearance,  and  was  perfectly  sound."  (The  state  of  the 
milk  not  mentioned.)  Case  XVI.,  "  the  contents  of  the  pelvis 
were  sound."  Milk  not  mentioned.  In  none  of  these  cases  is 
there  any  mention  of  the  inflammation  of  the  ovaria. 

The  abd'omen,  we  have  said,  does  not  swell  in  hysteritis ;  un- 
less it  be  merely  in  proportion  to  the  increase  of  size  of  the 
uterus  itself.  This,  however,  we  have  seen  pretty  considerable, 
owing  to  confined  coagula,  but  which  has  always  subsided  so 
soon  as  these  were  expelled  by  the  contractions  of  the  uterus. 
Indeed,  this  circumstance  alone  produces  much  pain ;  and,  for  a 
short  time,  even  threatens  more  serious  mischief:  especially  as 
this  takes  place  while  the  uterus  is  labouring  under  inflammation, 
as  we  have  had  occasion  more  than  once  to  see :  the  sufferings 
then  are  very  severe  and  even  menacing.  Under  such  circum- 
stances, we  have  known  the  uterus  to  acquire  a  size  nearly  equal 
to  that  at  the  seventh  month  of  pregnancy. 

In  this  case  the  abdomen  becomes  very  tender,  and  the  system 
is  always  excited  to  fever ;  the  pain  is  constant,  and  scarcely  to 
be  borne;  for  now  the  uterus  is  suddenly  put  upon  the  stretch, 
and  this  during  its  inflamed  condition.  But  this  state,  as  far  as 
we  have  witnessed,  does  not  continue  long;  for  the  uterus  be- 
comes stimulated  to  contraction  after  being  thus  painfully  dis- 
tended ;  its  mouth  opens,  and  the  coagula  are  either  expelled  by 
one  or  two  efforts,  or  it  may  require  a  number  for  this  purpose. 

After  the  removal  of  these  offensive  clots,  the  woman  is  greatly 
relieved,  and  she  is  rarely  exposed  to  a  second  attack. 

In  hysteritis,  then,  so  long  as  the  disease  maintains  the  cha- 
racter of  the  first  species,  the  abdomen  may  be  considered  as  but 
little  affected;  nor  does  it  suffer  at  any  period  of  the  disease  as 
it  does  in  puerperal  fever,  either  original,  or  induced;  as,  for  in- 
stance, in  the  second  species  of  hysteritis.  On  this  account,  the 
sufferings  are  not  so  severe,  and  the  woman  is  enabled  to  change 
her  position,  without  that  intensity  of  suffering  which  she  expe- 
riences from  the  same  effort  in  peritonitis. 

The  bowels  are  variously  affected;  but  in  the  beginning,  as 


340  INFLAMMATION    OF   THE   UTERUS. 

in  peritonitis,  they  are  generally  disposed  to  constipation ;  or  this 
complaint  may  be  ushered  in  by  diarrhoea ;  but  this  is  rare,  though 
no  unusual  attendant  in  the  progress  or  last  stage  of  the  disease, 
though  it  may  become  critical. 

The  symptoms  we  have  just  detailed  may  be  looked  upon  as 
constituting  the  first  stage  of  this  disease;  or  the  stage  of  high 
inflammatory  action,  which  may  terminate  either  in  resolution, 
or  in  suppuration. 

When  this  disease  is  about  to  yield,  there  is  an  alleviation  of 
all  the  more  distressing  symptoms ;  there  is  a  softening  or  re- 
duction of  the  uterine  tumour,  with  an  abatement  of  its  tender- 
ness; the  pulse  loses  its  febrile  and  inflammatory  character;  it  is 
less  frequent,  softer,  and  more  yielding;  the  skin  becomes  re- 
laxed, and  disposed  to  become  moist.  Headache  abates,  and  de- 
lirium, if  it  had  been  present,  subsides;  the  tongue  begins  to  clean, 
and  the  thirst  diminishes ;  the  lochia  return,  and  their  appear- 
ance changes  to  a  more  florid  colour.  The  urine  becomes  more 
abundant,  and  less  high  coloured;  the  milk  is  more  freely  se- 
creted, &c. 

But  should  the  disease  not  have  abated,  either  owing  to  its  in- 
tensity, or  the  feebleness  of  the  means  employed,  the  inflamma- 
tion may  terminate  by  suppuration  in  various  parts  of  the  proper 
substance  of  the  uterus,  and  which  is  almost  sure  to  be  followed 
by  death.  Sometimes,  however,  there  is  reason  to  believe  that 
the  abscess  opens  within  tb.e  cavity  of  the  uterus,  and  escapes 
through  the  os  uteri;  in  which  case  the  woman  may  recover. 
"We  have  seen  two  or  three  instances,  in  which  we  believe  this 
had  occurred. 

A  disposition  to  suppuration  may  be  suspected,  from  the  pulse 
becoming  more  irritated ;  by  its  increasing  both  in  frequency  and 
quickness ;  by  the  skin  being  alternately  partially  dry  and  moist ; 
chills  of  more  or  less  intensity,  with  dark  flushings  on  the  cheek, 
or  cheeks :  by  the  tongue  becoming  dry  and  red;  by  the  lochia 
escaping  in  a  larger  quantity,  but  very  fetid ;  in  a  word,  the  wo- 
man now  sinks  from  irritative  fever.  Or,  the  inflammation  may 
communicate  itself  to  the  peritoneal  coat  of  the  uterus,  by  pass- 
ing along  the  Fallopian  tubes,  or  otherwise;  and  thus  adding 
puerperal  fever  to  the  inflammation  of  the  uterus,  making  the 
second  species. 

SPECIES  II. 

The  mixed  Inflammation  of  the  Uterus,  or  accidental  or  /Second- 
ary Puerperal  Fever. 

When  the  peritoneum,  covering  either  the  uterus,  or  its  ap- 
pendages, becomes  the  seat  of  inflammation,  the  disease  is  called 


f: 


INFLAMMATION    OF    THE    UTERUS.  341 

by  Dr.  Clarke,  a  mixed  case;  and  is  one  of  almost  certain  fata- 
lity. For  we  have  an  inflammation  now  besieging  two  very 
different  tissues  or  structures,  and  its  effects  upon  either  may  bo 
sufficient  to  destroy  life. 

This  extension  of  inflammation  may  be  always  dreaded,  when 
the  first  species  remains  unsubdued;  especially  after  a  vigorous 
treatment  has  been  pursued;  for  it  now  betrays  a  disposition  to 
run  on  to  its  second  stage.  This  extension  of  inflammation  to 
the  peritoneum  announces  itself  by  the  addition  of  several  new 
symptoms  to  the  unpleasant  ones  belonging  to  the  second  stage 
of  the  first  species ;  such  as  a  great  increase  in  the  frequency  of 
the  pulse;  hiccough;  tenderness  and  swelling  of  the  abdomen; 
vomiting ;  an  inability  to  lie,  other  than  on  the  back ;  a  total  stop- 
page of  the  lochia ;  a  cessation  of  the  mammary  secretion  ;  cold 
sweats ;  muttering  delirium ;  a  dry,  husky,  blackish  tongue ; 
diarrhoea,  &c. 

When  the  disease,  by  its  extension,  becomes  the  second  species 
of  hysteritis,  it  may  be  considered  as  almost  necessarily  fatal :  at 
least  we  recollect  no  instance  of  recovery.  Nor  is  this  surpri- 
sing; since  a  highly  dangerous  complaint  makes  its  appearance 
at  a  time  the  system  is  debilitated  from  the  force  of  a  previous 
disease,  and  the  effect  of  remedies  ;  and  is  from  these  causes  un- 
able to  support  the  farther  use  of  means  for  its  relief.  The 
patient,  therefore,  almost  necessarily  dies. 

Dr.  Clarke  has  furnished  us  with  the  appearance  of  the  parts 
after  death,  in  both  species  of  inflammation  of  the  uterus.  He 
says,  "  Upon  examining  the  bodies  of  women  who  have  died 
under  this  disease,  we  have  found  little  or  no  extravasated  or 
secreted  fluids  in  the  cavity  of  the  abdomen,  when  the  disease 
has  existed  simply.  The  peritoneal  surfaces  have  been  also  dis- 
covered free  from  disease  in  some  cases ;  in  others,  however,  the 
peritoneum  which  covers  the  uterus  has  been  partially  inflamed, 
and  that  covering  the  posterior  part  of  the  bladder.  Inflamma- 
tion is  often  observed  running  along  the  Fallopian  tubes,  which, 
when  cut  into,  will  be  seen  loaded  with  blood.  The  ovaria,  too, 
are  often  affected  in  the  same  way. 

"  The  uterus  will  commonly  be  found  very  firm  in  its  sub- 
stance, but  larger  than  when  naturally  contracted.  Upon  cut- 
ting into  the  substance  of  the  uterus,  pus  is  often  found,  which, 
in  all  the  cases  I  have  met  with,  is  situated  in  the  large  veins  of 
that  part.1  Pus  is  also  sometimes  found  in  the  cavity  of  the 
Fallopian  tubes,  and  also  in  the  substance  of  the  ovaria,  which 
are  distended  by  inflammation  and  matter,  so  as  to  equal  in 
bulk,  in  some  cases,  a  pigeon's  egg. 

1  In  these  cases  it  is  more  than  probable  that  the  disease  was  a  genuine  phle- 
bitis of  the  uterine  veins. 


342  INFLAMMATION    OF    THE    UTERUS. 

"I  have  never  had  occasion  to  meet  with  any  case  in  which 
mortification  had  taken  place  in  any  part  of  the  substance  of  the 
uterus,  except  in  one  instance,  where  there  was  a  gangrenous 
appearance  of  the  cervix ;  but  it  is  to  be  remarked,  that  instru- 
ments had  been  employed  in  that  case,  by  the  gentlemen  who 
attended  the  labour."  Essays,  p.  69. 


Treatment. 

The  history  of  this  disease  will  suggest  at  once  its  general 
treatment. 

a.   Of  Bleeding. 

The  high  inflammatory  character  of  this  complaint,  especially 
in  this  country,  declares  the  necessity  of  the  most  ample  deple- 
tion, and  the  most  abstemious  diet. 

Blood-letting  must  be  employed  to  the  full  extent  the  system 
will  well  bear  ;  or  it  will  not  and  cannot  be  successful.  The 
extent  of  bleeding  in  this  disease  must  be  regulated  only  by  its 
effects  ;  its  quantity  must  ever  be  of  minor  consideration,  so  long 
us  the  symptoms  continue  to  demand  its  repetition.  Dr.  Clarke 
says,  "  In  the  repetition  of  the  operation,  (bleeding,)  we  must  be 
governed  by  the  same  circumstances,  and  the  effect  of  the  former 
evacuation  upon  the  disease ;  and  it  must  be  observed,  that  it 
will  frequently  be  found  necessary,  not  only  a  second,  but  a  third 
time,"  p.  73. 

From  the  histories  of  the  dissections  of  those  who  have  died 
of  hysteritis,  it  is  evident  that  nothing  but  very  ample  blood- 
letting and  other  depletions,  can  prevent  the  fatal  termination  of 
this  disease  ;  or,  at  least,  prevent  its  ending  in  suppuration,  from 
which  the  escape  with  life  must  necessarily  be  rare.  And  though 
this  disease  is  declared  by  Dr.  Clarke,  to  be, "  of  all  the  serious 
complaints  which  attack  the  woman  in  the  puerperal  state,  the 
least  fatal,"  he  is  not  to  be  understood  to  mean,  that  this  is  the 
case  when  this  complaint  is  badly  treated.  For  immediately 
after,  he  says,  "Every  art  which  has  a  tendency  in  any  manner 
to  diminish  the  quantity  of  the  circulating  fluids,  and  weaken  the 
action  of  the  heart  and  arteries,  should  be  employed  in  order  to 
subdue  the  inflammation  at  the  very  outset,"  p.  72. 

This  exactly  corresponds  with  our  own  experience  in  this  dis- 
ease :  we  have,  in  every  instance  in  which  we  have  encountered 
it,  abstracted  blood,  both  from  the  system  at  large  by  bleeding, 
and  also  by  large  leechings  upon  the  abdomen.  With  regard  to 
blood-letting,  our  plan  has  generally  been  as  follows :  to  bleed 
from  the  arm,  until  it  produces  sickness  of  stomach,  at  least ;  if 


INFLAMMATION   OF  THE   UTERUS. 

syncope  take  place,  we  have  no  objection.  It  will  almost  always 
be  found,  after  this,  that  the  fever  and  other  signs  of  inflamma- 
tion will  be  much  diminished ;  but  this,  in  many  cases,  will  be  of 
short  duration ;  for  the  system,  if  the  bleeding  has  not  been  suffi- 
cient to  "strangle"  the  disease,  will  react  in  the  course  of  a  few 
hours,  and  pain,  fever,  &c.,  will  again  be  renewed.  Whenever 
this  takes  place,  be  the  period  longer  or  shorter,  it  is  to  be  re- 
peated again  and  again;  nor  do  we  know  any  reason  for  stopping, 
but  the  reduction  of  the  disease. 

But  our  bleedings  are  not  always  renewed  from  the  arm;  for, 
as  soon  as  we  get  the  pulse  pretty  well  down  by  this  means,  we 
have  leeches  applied  over  the  parts  nearest  to  the  fundus  of  the 
uterus,  and  also  to  the  vulva,  in  such  numbers  as  shall  abstract 
at  least  eight  or  ten  ounces  of  blood,  and  encourage  their  after- 
bleeding  by  the  application  of  moist  warmth.  Should  these 
abstractions  j)f  blood  not  prove  effective,  and  pain,  fever,  and 
other  unpleasant  symptoms  continue ;  but  especially,  great  pain 
and  tenderness  in  the  parts ;  if  the  pulse  does  not  call  for  general 
bleeding,  we  repeat  the  leeching,  nor  stop  until  the  end  is  an- 
swered, or  until  we  are  convinced  our  efforts  will  be  unavailing, 
by  the  approach  of  the  second  stage,  or  by  the  addition  of  peri- 
toneal inflammation. 

Perhaps  there  is  scarcely  a  disease  which  demands  such  ex- 
tensive bleeding  as  the  simple  hysteritis;  several  reasons  concur 
to  render  this  necessary,  nay,  indispensable. 

First,  from  delivery  having  lately  taken  place,  the  uterus  is 
much  engorged  with  blood,  at  the  period  at  which  it  is  attacked 
by  inflammation ;  its  vessels,  therefore,  are  still  distended,  and 
its  whole  substance  in  a  highly  irritable  state ;  consequently,  a 
new  quantity  of  blood  is  invited  to  its  parietes. 

Secondly,  owing  to  the  insulated  position  and  independent 
economy  of  this  organ,  it  becomes  very  readily  filled  with  blood, 
but  parts  with  it,  unless  under  particular  circumstances,  as  in 
hemorrhages  from  this  part,  with  great  difficulty,  or  at  least  ver/ 
slowly,  as  is  proved  by  its  bulk  several  days  after  delivery ;  con- 
sequently, large  quantities  may  be  taken  from  the  general  system 
without  greatly  influencing  the  quantity  contained  in  the  sub- 
stance of  the  uterus. 

Thirdly,  owing  to  the  lax  and  distensible  condition  of  the  ute- 
rine vessels,  they  are  readily  restretched  by  any  influx  of  blood; 
and  consequently,  they  again  become  charged  by  a  fresh  quantity 
of  it,  which  now  becomes  another  cause  of  irritation  (by  disten- 
tion,)  to  the  newly  provoked  inflammation ;  and  thus  inviting  a 
greater  flux  of  blood  to  this  parti 

Fourthly,  that  when  the  uterus  becomes  thus  re-filled,  the  ves- 
sels cannot  be  relieved  from  this  engorgement,  as  the  only  agent 
by  which  their  capacities  can  be  diminished,  and  of  course,  this 


344  INFLAMMATION   OF   THE   UTERUS. 

state  relieved,  is  now  suspended,  (namely,  the  tonic  contraction 
of  this  organ:)  hence  the  enlargement  of  this  viscus  in  this  dis- 
ease; and  hence  it  is  a  favourable  symptom,  when  it  diminishes 
in  size,  as  it  shows  a  return  of  the  tonic  contraction,  and  conse- 
quently, an  abatement  of  inflammation. 

All  these  circumstances  show  the  necessity  of  blood-letting : 
.and  at  the  same  time  prove,  that  it  will  require  much  to  be  ab- 
stracted, before  this  particular  condition  of  the  uterus  can  be  re- 
lieved. It  also  shows  us  the  importance  and  propriety  of  local 
bleeding,  by  either  leeching  or  cupping ;  as  the  blood  abstracted 
by  these  means  acts  with  more  certainty,  as  well  as  more 
promptly,  upon  this  part. 

'j'jAti&fs  Herfa  «uv'«£xJftM/a  jjbifca  #ri  ^yfer.r  esli/p*  oafas  bmt 
-tOjl«  •iivtlr  si'fiiLfflort')  h/iB  jfoioiJ  1o  r  finfto  &ti  10  4d^?5 
W4£-  4<W    b'    Of  Purging. 


.'•  To  co-operate  with  bleeding,  purging  has  been  advised;  this, 
to  say  the  least,  is  a  doubtful  remedy.  Dr.  Clarke  says,  "  Neither 
can  I  recommend  a  course  of  purging,  as  serviceable  in  the  in- 
flammation of  the  uterus,  which  follows  delivery.  It  is  always, 
I  believe,  right,  in  the  first  instance,  to  procure  two  or  three 
stools ;  but  afterwards,  it  will  be  enough  to  preserve  the  regular 
motions  of  the  bowels,  by  giving,  from  time  to  time,  small  quanti- 
ties of  castor  oil,  or  a  little  rhubarb,  mixed  with  other  medicines, 
which  may  be  proper.  The  objection  which  I  have  found  to 
long-continued  purging  is,  it  has  always  the  effect  of  preventing 
that  gentle  perspiration,  which,  if  it  can  be  produced  and  kept 
up,  will  do  more  towards  curing  the  disease  than  any  remedy 
which  I  know,"  p.  75. 

The  bowels  should  be  kept  open  by  the  gentlest  means ;  of 
these  the  clyster  is  the  best  remedy.  This  should  be  done  daily 
at  least. 

' '  «ft-:'  Of  Fomentations. 
-flfla  ;  £mibt>  v»fU  w.l  I*-i.<>.rtfa  #u<i  a«  Y/  fcwwq,  «     i  ^UM. 

Dr.  Clarke  recommends  fomentations  to  the  abdomen :  we  never 
advise  them,  for  we  have  never  seen  them  of  the  slightest  use  in 
hysteritis,  and  we  have  known  them  to  do  mischief.  They  do  mis- 
chief by  the  intensity  of  their  heat ;  by  their  weight,  by  exposing 
the  woman  to  chills;  and,  by  keeping  her  constantly  wet.  They 
are  particularly  inadmissible  in  the  early  stage  of  this  disease, 
as  they  increase  the  circulation  by  their  warmth. 

In  such  cases  of  hysteritis  as  may  be  accompanied  by  after- 
pains  arising  from  coagula  within  the  uterus,  which  is  known,  as 
we  have  said,  by  its  alternate  movements,  we  have  seen  an  ap- 
plication of  dry,  or  merely  moist  substances,  very  useful;  by 


INFLAMMATION   OF   THE   UTERUS. 

promoting  the  contractions  of  the  uterus  so  as  to  expel  these 
foreign  bodies.  The  one  we  have  most  commonly  used  is  the 
"  tansy  pan-cake."  This  is  made  by  mixing  flour  and  water 
together  to  the  consistence  of  a  batter,  and  adding  to  it  a  quantity 
of  tansy  :  and  then  to  be  fried  like  a  pan-cake  ;  but  made  much 
thicker;  (say  half  an  inch,)  when  done,  it  is  to  be  placed  be- 
tween two  cloths,  and  is  applied  to  the  abdomen.  Under  these 
circumstances,  for  which  we  recommend  this  application,  it  will, 
we  think,  be  found  highly  useful  :  at  least  it  has  proved  repeat- 
edly so  with  us.  It  certainly  combines  all  the  good  properties  of 
the  fomentation,  without  its  disadvantages;  but  let  it  be  clearly 
understood,  its  employment  is  confined  to  the  cases  above  stated  ; 
namely,  where  the  uterus  distended  with  coagula  produces  much 
pain,  and  the  ordinary  efforts  of  this  organ  are  found  insufficient 
to  expel  them. 

The  French  are  fond  of  fomentations,  but  we  think  too  much 
good  is  ascribed  to  them. 


..  .    »  ..    ><•-     ,    .  . 

d.  Of  Blisters. 

It  is  very  doubtful  whether  blistering  the  abdomen  in  cases  of 
hysteritis  is  of  benefit  :  we  are  at  a  loss,  from  what  we  have 
seen,  how  to  decide;  their  efficacy,  if  they  possess  any,  is  un- 
questionably very  limited.  Dr.  Clarke  and  others  are  decidedly 
against  their  use,  and  we  are  rather  disposed  to  coincide  with 
them  ;  not  that  we  are  satisfied  they  are  injurious,  but  because 
we  are  not  convinced  they  are  decidedly  useful,  and  because 
they  are  very  inconvenient,  especially  to  such  patients  as  may 
have  diarrhoea.  It  is  many  years  since  we  last  used  them  ;  and 
we  cannot  venture  to  recommend  them.  They  are  too  pertur- 
bating. 


e.   Of  Sudorifics. 
A,  M>C.. :.;.!;, -i^qi,  Uiv  )l ,  'i?i\ti-nii  :--\'>-         ^ 

Our  opinion  of  this  class  of  remedies  may  be  collected  from 
what  we  have  already  said  on  the  subject  of  "perspiration:"  we 
shall  only  add,  that,  in  the  early  stage  of  the  complaint,  their 
powers  are  altogether  inadequate  to  the  state  of  the  disease ;  and, 
when  it  is  on  the  decline,  they  are  generally  unnecessary.  We 
have  thought  them  occasionally  useful,  where  the  force  of  the 
pulse  had  been  abated  by  the  treatment,  and  nothing  but  a  little 
feverishness  came  on  in  the  evening,  accompanied  by  watchful- 
ness and  a  dry  skin.  We  think  we  have  seen  the  occasional  use 
of  Dover's  powder,  given  at  bed-time  in  ten-grain  doses,  useful. 


, 
njn  ; •  '«    • 

346  INFLAMMATION   OP  THE   UTERUS. 

But  our  rule  is,  never  to  rely  upon  them,  to  the  exclusion  of  eva- 
cuants. 

f.   Of  Opium. 

-1          ;;<!  t:J  iu)A3  )*$x  ^y^n*;;  w 

In  the  commencement  of  the  disease,  the  pain  which  sometimes 
attends  hysteritis  has  led^to  the  free  use  of  opium;  but  it  is  al- 
ways unfortunate  for  the  patient:  for  it  never  subdues  the  pain, 
and  it  is  sure  to  augment  the  existing  evils  by  its  stimulus,  and 
by  its  constipating  effects  upon  the  bowels.  It  is,  therefore,  clear, 
it  is  not  proper  in  the  beginning  of  the  disease ;  nor  is  it  much 
more  eligible  in  its  decline,  as  it  may  interrupt  the  discharges 
from  the  bowels  at  a  time  they  may  be  much  needed.  In  com- 
bination, as  in  Dover's  powder,  it  may  be  now  and  then  useful; 
but  we  think  no  decided  advantage  is  gained  by  its  use,  unless  it 
be  to  relieve  some  sudden  symptom,  as  severe  and  unexpected 
pain  in  the  bowels,  from  flatulency,  or  other  causes,  when  the 
fever  is  pretty  well  under  command ;  to  moderate  unnecessarily 
severe  purging,  or  hypercatharsis,  or, to  give  temporary  comfort 
to  an  exhausted  or  irrecoverable  patient.  Indeed,  if  depletion 
has  been  ample,  there  is  very  little  use  in  the  opium.1 


g.   Of  Emetics. 

Emetics  have  been  thought  highly  useful  in  almost  every  com- 
plaint of  the  puerperal  woman.  From  their  reputed  efficacy  in 
peritoneal  inflammation,  as  recommended  by  Mr.  Doulcet,  they 
have  been  thought  useful  in  inflammation  of  the  uterus,  and,  ac- 
cordingly, have  been  recommended  in  such  cases.  Our  expe- 
rience exactly  coincides  with  that  of  Dr.  Clarke  on  this  point, 
that  they  "constantly  add  to  the  pain,  by  the  agitation  they  oc- 
casion, and  the  pressure  made  by  the  muscles  on  the  inflamed 
uterus,"  p.  77. 

From  all,  then,  that  has  been  said  upon  the  various  remedies 
proposed  for  the  relief  of  this  disease,  it  will  appear  that  our  de- 
pendence is  chiefly  upon  bleeding  and  purging.  The  treatment 
for  the  second  species,  or  the  mixed  inflammation  of  the-uterus, 
will  be  learnt  under  the  head  of  Puerperal  Fever. 

'Dr.  Clarke  is  much  in  favour  of  opium  in  this  disease;  this,  perhaps,  arises 
from  his  not  carrying  bleeding  and  purging  as  far  as  we  are  in  the  habit  of  doing; 
the  consequence  is,  that  pain  is  much  more  permanent,  in  cases  which  have  not 
been  freely  held,  and  may  require,  for  temporary  purposes,  the  aid  of  laudanum. 
Its  indiscriminate  use,  however,  cannot  be  too  severely  condemned,  in  diseases 
of  high  action. 

™i>«.w>«j!;  :  i'jptr  ifrwff  otf"   ..i\\fa^Wk:ln&  *Y' 

«**  -'';'   •?">  •  '•£' 


PUERPERAL    FEVER.  347 


CHAPTER  XVIII. 


OF  PUERPERAL  FEVER. 

-  f;<t.i ,  -  •   <,»,    .??'*?.-   '  •-.:*.    "<'•   i* 

THIS  term,  by  some,  is  now  looked  upon  as  generic;  and 
should,  therefore,  be  employed  w}th  more  severe  restrictions 
than  it  formerly  was.  Dr.  Conquest  says,  that  "in  reality  it 
designates  only  a  prominent  symptom  of  disease,  but  which,  in 
ordinary  usage,  embraces  complaints  having  little  or  no  resem- 
blance or  connexion,  either  in  their  essential  nature,  their  seat, 
or  their  treatment.  For  I  fearlessly  appeal  to  every  cautious, 
intelligent,  and  reflecting  man,  whether  the  term  is  not  in  daily 
use  equally  to  designate  spasmodic  and  inflammatory  affections 
of  the  peritoneal  investments  of  the  uterus,  and  abdominal  vis- 
cera; inflammation  of  the  muscular  fibres;  inflammation  of  the 
veins  of  the  uterus ;  phrenitis;  irritative  fever;  diarrhoea;  and 
spasms  of  the  intestinal  canal,  so  frequently  confounded  with  in- 
flammation."1— Observations  on  Puerperal  Fever. 

If  this  statement  be  true,  and  we  have  no  doubt  but  it  is,  from 
the  respectability  of  the  authority,  the  term  puerperal  fever  is  used 
in  Great  Britain  much  more  vaguely  than  in  this  country.  And 
though  our  notions  respecting  this  disease  are  not  logically  accu- 
rate, they  are,  nevertheless,  more  definite  than  they  appear  to 
be  in  England,  agreeably  to  Dr.  Conquest.  For  we  do  not  be- 
lieve that  any  well-instructed  practitioner  here  would  agree  to 
call  all  the  affections  enumerated  above,  by  the  sweeping  term, 
"Puerperal  Fever."  We  have  observed  already,  in  treating  of 
the  inflamed  womb,  that  much  confusion  existed;  as  both  hys- 
teritis  and  peritonitis  were  expressed  by  the  same  term ;  though 
very  different  tissues  were  implicated  in  the  two  diseases :  yet 
with  this  admission,  we  are  by  no  means  prepared  to  say  at  this 
moment,  that  much  practical  mischief  has  arisen  from  this  wrong 
location  of  the  inflammation,  as  both,  caeteris  paribus,  require 
very  much  the  same  treatment,  though  we  profess  to  be  warm 
sticklers  for  correct  pathology.  We  will,  therefore,  at  once,  de- 
clare, that  by  puerperal  fever  we  understand,  inflammation  of 

.  lj  •  -  '•.  •'  i  0'','  i '.   '"  j r  \  '  •'  .•  ;  it*.".          *r>'>  !  *  '.Ki 

1  For  these  reasons  M.  Tonnelle  prefers  the  term  puerperal  fever  to  more  spe- 
cific names,  as  we  shall  have  occasion  to  say  presently.  Strictly  speaking,  puer- 
peral fever  means  a  fever  that  may  attack  a  woman  in  child-bed — and,  as  the  term 
has  no  pathological  meaning,  it  is  preferred  by  the  writer,  as  it  will  embrace  all 
the  febrile  affections  to  which  the  woman  may  be  liable  after  delivery,  however 
varied  their  seat  or  nature. 


348  PUERPERAL    FEVER. 

some  one  portion  or  other  of  the  peritoneum,  which  attacks  wo- 
men almost  immediately,  or  within  a  few  days  after  their  delivery ; 
and  is  distinguished  from  every  other  affection  of  the  febrile  kind, 
by  being  always  attended  by  a  more  highly  accelerated  pulse ; 
by  a  painful  soreness  of  the  abdomen;  and  with  more  or  less 
distention,  (after  a  short  time,)  of  this  cavity.  This  disease  is 
frequently,  but  not  always,  ushered  in  by  a  chill. 

For  however  much  authors  may  disagree  about  the  essential 
nature  of  this  disease,  its  remote  and  proximate  causes,  or  its 
mode  of  treatment,  they,  nevertheless,  one  and  all  consent  to  con- 
sider the  marks  just  stated  to  be  its  pathognomonic  symptoms. 
And,  perhaps,  in  no  disease  of  the  febrile  kind,  can  so  many  pe- 
culiarities be  enumerated,  as  almost  constantly  present  them- 
selves in  this ;  such  as  the  highly  accelerated  pulse  ;  the  failure  in 
the  secretion  of  the  milk,  if  it  has  not  taken  place  previously  to 
the  attack  of  the  disease;  its  almost  immediate  arrest,  if  it  has 
begun  to  be  formed;  the  diminution  or  suppression  of  the  lochia; 
the  constipated  condition  of  the  bowels ;  the  peculiar  character 
of  the  alvine  discharges;  the  exemption,  for  the  most  part,  from 
delirium;  the  loss  of  maternal  feeling,  &c. 

The  fatal  character  of  this  fever  is  almost  proverbial :  Dr.  Den- 
man  declares  "it  occasions  the  death  of  much  the  greater  part 
of  those  who  die  in  child-bed;"  and  many  others  bear  a  like  tes- 
timony of  its  dangerous  tendency.  Dr.  Clarke  declares,  that 
three  out  of  four  die.  "Perhaps  there  is  scarcely  a  disease  with 
which  we  are  acquainted,  whose  consequences  are  more  fatal 
than  this;  as  far  as  I  have  observed,  three-fourths  of  those  who 
have  been  seized  have  fallen  sacrifices  to  its  severity."  Essays, 
p.  132. 

The  accuracy  of  this  statement  may,  at  the  present  time,  be 
very  well  questioned,  if  accuracy  in  pathology  be  strictly  adhered 
to — for  it  is  but  just  to  suppose,  that  in  the  time  of  Dr.  Denman 
and  Dr.  Clarke,  and  as  it  has  almost  ever  been  since,  agreeably 
to  Dr.  Conquest,  many  other  complaints,  nay,  almost  all  of  the 
febrile  kind  that  befell  the  lying-in-woman,  were  called  puerperal 
fever.  This  indiscriminate  use  of  the  term  is  found  much  fault 
with,  as  we  have  just  shown,  by  Dr.  Conquest,  while  M.  Ton- 
nelle  prefers  the  term  to  peritonitis,  or  metro-peritonitis,  as  being 
more  comprehensive ;  and  as  it  expresses  nothing  of  itself — that 
is,  that  it  has  no  pathological  reference ;  for  he  has  satisfactorily 
shown  that  neither  peritonitis,  nor  metro-peritonitis,  will  express 
the  pathological  condition  of  all  that  have  fever,  or  die  in  child- 
bed ;  or  by  puerperal  fever,  if  we  employ  the  term  specifically. 

Thus,  M.  Tonnelle  found,  that  in  222  cases  of  puerperal  or 
child-bed  fever,  the  peritoneum  was  found  affected  in  193 ;  the 
uterus  and  its  appendages  in  197.  In  165  cases,  the  changes  in 
the  peritoneum  and  uterus  were  differently  combined;  those  of 


PUERPERAL   FEVER.  349 

the  peritoneum  simply  were  28,  those  of  the  uterus  were  29.  In 
79  cases,  the  alterations  of  the  uterus  were  produced  by  simple 
metritis;  superficial  ramollissement,  29;  profound  ramollissement, 
20;  inflammation  of  the  ovaries,  58;  with  ulcers,  14;— -total  190. 

Alterations  in  the  uterine  veins  and  lymphatics — pus  was  found 
in  90  instances  in  the  veins :  in  32  it  was  found  in  the  lymphatics ; 
and  in  3,  it  was  observed  in  the  thoracic  duct ;  with  inflammation 
and  suppuration  of  the  inguinal  and  lumbar  glands,  in  9  instances, 
making  134; — total  changes  effected  in  the  uterus,  324. 

Suppuration  of  the  veins  of  the  uterus,32;  with  ramollisse- 
ment or  putrescency,  11;  with  metritis  and  ramollissement,  5; 
with  peritonitis  without  any  other  alteration,  34 ;  entirely  insu- 
lated, 8 ; — total  90. 

Suppuration  of  the  lymphatics  with  the  veins,  20 ;  with  those 
of  the  uterus,  13 ;  with  ramollissement  of  the  uterus  with  suppu- 
ration, 6 ;  with  simple  peritonitis,  3 ;  without  any  other  alteration, 
2;— in  all  44. 

Inflammation  of  the  ovaries  with  simple  peritonitis,  29 ;  with 
alterations  of  the  uterus,  27 ;  with  simple  metritis,  8 ;  without 
any  other  alterations,  2 ;  in  all  62.1 

It  appears  from  these  tables  that  the  alterations  of  the  uterus 
exceed  by  a  little  those  of  the  peritoneum,  if  taken  collectively ; 
but  if  taken  alone,  they  very  much  exceed  them.  And  that  in 
134  cases  there  was  pus  in  the  veins  and  lymphatics. 

It  is  difficult  to  assign  the  cause  of  the  results  observed  by  M. 
Tonnelle ;  for  they  differ,  (if  other  observers  are  correct,)  from 
what  would  seem  to  be  the  experience  of  others  upon  this  point. 
As  regards  our  own  experience  in  autoptic  examination,  we  arre 
willing  to  take  it  at  its  absolute  value,  for  our  opportunities  have 
been  nothing,  when  compared  with  those  of  M.  Tonnelle;  yet 
the  little  we  have  seen  leads  to  a  belief  that  there  must  have 
existed  some  predominating  cause  for  the  very  frequent  lesions 
of  the  uterus  itself;  as  we  very  rarely  have  witnessed  any  altera- 
tions in  that  organ,  in  the  few  bodies  we  have  examined.  Besides, 
neither  Leake,  Hulme,  Clarke,  Hey,  nor  Armstrong,  have  made 
the  same  observations.  Nor  do  we  think,  that  the  result  of  hos- 
pital experience  is  always  the  best  authority  for  the  character  of 
any  disease,  as  this  is  known  to  be  modified  by  local  causes,  how- 
ever inscrutable  these  causes  may  be.  We  are  therefore  much 
inclined  to  the  belief,  that  peritoneal  inflammation  is  very  much 
more  common  in  this  country,  than  metritis,  properly  so  called; 
for,  if  the  abdominal,  or  that  portion  of  the  uterus  that  is  covered 
by  peritoneum,  be  inflamed,  and  no  other  tissue  of  this  organ,  it 

1  It  is  proper  to  remark,  lest  this  table  should  appear  to  contradict  itself,  that 
the  reason  the  whole  amount  of  the  two  classes  of  affections  exceeds  in  num- 
ber all  the  cases  dissected,  is,  that  in  many  cases  peritonitis  was  complicated  with 
metritis. 


350  PUERPERAL    FEVER. 

is,  to  all  intents  and  purposes,  peritonitis,  and  not  metritis.  But 
be  this  as  it  may,  the  observations  of  M.  Tonnelle  are  no  less 
interesting  than  curious ;  and  he  has  proved,  that  of  the  very 
many  deaths  of  women  in  child-bed,  a  large  proportion  of  them 
was  not  owing  to  acute  peritonitis,  as  metritis  and  phlebitis  of 
the  uterus  come  in  for  a  large  share;  at  least  this  was  found  to 
be  the  case  in  hospital  practice. 


a.  History  of  Puerperal  Fever. 

In  Europe,1  it  frequently  becomes  epidemic;  and  when  this 
happens,  its  ravages  are  sometimes  truly  awful,  as  its  malignity 
is  thought  to  be  increased  by  the  peculiar  constitution  of  the  air, 
which  renders  it  epidemical.  In  this,  almost  all  the  writers  upon 
this  subject  agree.  Dr.  Leake  says,  "It  will  always  be  found 
most  fatal  when  most  epidemical,  that  is,  during  the  distempera- 
ture  of  the  air;  and  least  of  all  so,  when  it  happens  in  healthy 
seasons,  from  accidental  causes." — Obser.  on  Child-bed  Fevers, 
p.  101.  Mr.  Hey  and  others  declare  the  same  thing. 

In  this  country,  this  disease  very  rarely  presents  itself  as  an 
epidemic;  the  only  record  of  this  kind  that  offers  itself  to  my 
recollection  at  this  moment,  is  that  of  Dr.  Jackson.  He  says,  it 
prevailed  "both  in  Northumberland  and  Sunbury,  in  this  state, 
(Pennsylvania,)  in  the  fall  of  1817,  and  in  the  spring  of  1818. 
And  though  treated  evidently  with  both  vigour  and  ability,  about 
one  half  died." — Eclectic  Repertory,  vol.  viii.  p.  202. 

•So  far  as  we  know,  this  disease  has  never  appeared  as  an  epi- 
demic in  this  city ;  though  sporadic  cases  have  been  more  fre- 
quent at  one  time  than  at  another.  It  has  always,  however,  been 
a  disease  of  great  danger,  and  is  sure  to  excite  great  alarm  when- 
ever it  may  occur.  It  does  not  appear  to  attack  the  poor,  more 
frequently  than  the  females  in  the  higher  ranks  of  life  ;  for  when 
it  occurs,  one  class  seems  as  liable  to  it  as  another ;  if  we  can 
call  any  thing  happening  so  rarely  as  this  disease  does  with  us,  a 
liability. 

Yet,  notwithstanding  the  infrequency  of  this  disease  in  this 
place,  it  does  not  seem  to  invalidate  the  observation  of  Dr.  Den- 
man,  that  "  it  destroys  the  greater  part  of  the  women  who  die 

1  In  the  year  1746,  this  disease  raged  in  Paris  to  a  terrible  extent,  especially 
in  the  Hotel  Dieu.  It  attacked  only  the  poor  women;  yet  it  was  neither  so  vio- 
lent nor  so  common  when  they  were  delivered  at  their  own  houses,  as  when 
placed  in  the  hospital.  In  this  place  it  was  remarked,  that  of  twenty  women  who 
were  attacked,  scarcely  one  escaped. 

The  character  of  the  disease,  according  to  the  writers  of  that  day,  resembled  in 
every  particular  the  puerperal  fever  of  Great  Britain,  and  of  this  country. — Quoted 
by  Clarke,  in  Essays,  p.  104. 


PUERPERAL    FEVER.  351 

in  child-bed:"  for  when  deaths  occur  In  the  puerperal  state,  this 
disease  has  its  full  share  of  them.  But  deaths  in  child-bed  are 
comparatively  of  rare  occurrence  in  this  country,  when  contrasted 
with  their  frequency  in  Europe.  This  is  partly  owing  to  our 
not  having  a  class  of  people  that  exactly  corresponds  with  the 
class  called  "the  poor"  in  Europe  ;  and  among  whom  this  dis- 
ease commits  dreadful  ravages,  and  especially  at  the  time  it  be- 
comes epidemic. 

In  Great  Britain,  it  occurs  perhaps  more  frequently  as  an  epi- 
demic than  on  the  Continent;  the  cause  of  this  we  cannot  pre- 
tend to  explain ;  but  such  appears  to  be  the  fact.  Mr.  Hey  and 
others  describe  this  disease  as  an  epidemic  of  frequent  occurrence, 
and  one  that  visits  one  district  after  another,  without  any  appa- 
rent cause*  Thus,  he  tells  us,  that  "for  some  years  past,  the 
puerperal  fever  has  prevailed  epidemically  in  different  parts  of 
Yorkshire."  Again,  that  "it>  appeared  first  at  Barnsley,  twenty 
miles  south  of  Leeds,  where  it  was  prevalent  and  fatal.  It  be- 
gan there  early  in  the  year  1808,  nearly  two  years  before  it  be- 
came general  in  Leeds,"  p.  15. 

Again,  "About  two  years  before  the  fever  which  I  am  about 
to  describe,  made  its  appearance,  a  puerperal  fever  was  epidemic 
in  this  town,  (Leeds,)  which  was  similar  in  its  nature  to  that  now 
under  consideration ;  but  it  was  more  partial  in  its  extent,  afflict- 
ing only  one  district  of  the  town,  and  being  confined  chiefly  to 
the  poor,"  p.  15.  He  further  states  that  "  there  was  a  perpetua- 
tion of  this  disease  from  November,  1809,  to  about  Christmas, 
1812,"  p.  16. 

These  facts  incontestably  prove  the  frequency  and  the  extent 
of  the  disease,  (in  England,  at  least,)  when  compared  with  this 
country;  and  the  account  given  by  Mr.  Hey  is  but  one  of  many 
of  the  histories  of  this  epidemic,  which  has  occurred  in  Great 
Britain.  See  Dr.  Gordon,1  Dr.  Joseph  Clarke,*  Dr.  John 
Clarke,  &c,3 

We  are,  however,  not  to  be  understood  to  mean,  that  fevers 
do  not  occur  in  child-bed  in  this  country;  we  only  declare,  that 
this  particular  fever  is  one  that  we  very  rarely  see.  The  milk 
fever,  the  ephemeral  fever,  called  the  "weed,"  are  frequently 
met  with;  for  here,  as  well  as  elsewhere,  improprieties  during 

1  See  Dr.  Gordon's  account  of  the  puerperal  fever,  when  it  appeared  as  an  epi- 
demic in  Aberdeen,  in  Scotland. 

9  See  Dr.  Joseph  Clarke's  account  as  it  appeared  in  Dublin  in  17GO.  Duncan's 
Medical  Comment,  for  17i)0.  It  again  appeared  in  Dublin  in  1767. 

3  See  Dr.  John  Clarke's  account  of  the  low  fever  of  child-bed,  in  1787  and 
1788.  Mr.  White's  account  of  it  at  Manchester,  in  17H1.  Treatise  on  manage- 
ment of  lying-in  women,  p.  1H5.  Dr.  Leake's  account  for  1770,  as  it  appeared  in 
tne  Westminster  Hospital.  Prac.  Obs.  p.  241.  Mr.  White's  account  as  it  ap- 
peared in  Edinburgh  in  1773.  Tenon's  account  as  it  appeared  in  Paris  from  1774 
to  1781. 


I 

352  PUERPERAL    FEVE*. 

the  first  few  days  of  confinement  will  be  committed,  and  the  pa- 
tient be  subjected,  in  consequence,  to  the  fevers  just  mentioned.1 
Besides,  we  have  every  now  and  then  inflammation  of  the  womb, 
which  sometimes  passes  for  puerperal  fever. 

In  the  account  we  shall  give  of  this  disease,  we  shall  confine 
ourselves  to  that  inflammation  of  the  peritoneum  that  succeeds 
delivery.  For  we  are  of  opinion,  that  this  will  embrace  "the 
low  malignant  fever  of  lyingrin  women,"  as-  detailed  by  Dr. 
Clarke,  as  well  as  the  disease  described  by  Hulme,  Kirkland, 
Leake,  Denman,  Gordon,  Armstrong,  Hey,  &c.  It  is  true,  that 
several  of  these  include  in  their  accounts  what  they  term  an  in- 
flammation of  the  uterus,  as  Hey  and  Denman ;  yet  the  simple 
inflammation  of  the  uterus  is  a  very  different  disease  from  puer- 
peral fever :  so  much  so,  in  our  opinion,  that  they  should  never 
be  confounded ;  and,  for  this  reason,  we  have  given  them  a  sepa- 
rate consideration. 

^f  *'  o'1^  "li'uf  tft'f'^f  -trwi  >f  *; -^t*  .^>:Hi   vf '••>•'*  •>;!)  <<r  "-"/Til  >   ''Iji-ilj  'M^ 

b.   Of  the  Predisposing  Causes. 

Much  diversity  of 'opinion  exists  as  to  the  remote  or  predis- 
posing causes  of  puerperal  fever;  especially  when  it  may  appear 
as  an  epidemic.  Cold,  moisture,  labour  itself,  &c.,  have  been 
assigned:  but  it  seems  nothing  satisfactory  has  yet  been  ascer- 
tained upon  these  points.  For  M.  Tonnelle8  has  pretty  satisfac- 
torily ascertained  that  neither  cold  nor  moisture  can  be  looked 
upon  as  causes.  For  when  this  disease  raged  in  "la  Mater- 
nite,"  the  hospital  to  which  he  was  attached,  as  the  pupil  of  the 
late  M.  Desormeaux,  neither  of  these  powers  could  have  ope- 
rated as  regards  cold,  for  it  was  observed,  that  though  the  disease 
•was  very  common  in  January,  which  was  very  cold  and  dry, 
yet  in  December  it  was  very  rare,  though  this  month  was  similar 
as  regards  temperature  and  dryness  ;  and  the  agency  of  moisture 
appeared  to  be  equally  uncertain ;  for,  in  the  summer,  which  was 
both  cold  and  wet,  cases  were  numerous,  yet  they  were  rare  at 
other  times,  when  the  weather  was  similar ;  while  on  the  other 
hand,  they  were  very  common  during  the  spring,  when  the 
draught  was  very  unusual  in  length  and  duration.  In  a  word, 
the  disease  prevailed  in  its  greatest  extent  during  cold,  dry 
weather;  in  temperate  weather,  as  well  as  during  moist,  tem- 
perate weather — while  at  other  periods  of  the  year,  when  similar 
weather  prevailed,  the  disease  was  neither  more  frequent  nor 

1  We  consider  the  milk  fever  certainly,  and  the  "weed"  most  probably,  of  ar- 
tificial origin:  for  we  believe  we  are  correct  in  saying,  where  the  nursing  has 
been  properly  conducted,  they  never  appear;  or  if  they  do,  it  is  very  rarely. 

a  Des  Fievres  Puerperales  Observees  a  la  Maternite  de  Paris. 


PUERPERAL  FEVER.  353 

* 

more  severe.  Neither  could  the  frequency  or  severity  of  the  dis- 
ease be  traced  to  a  vitiation  of  the  atmosphere  of  the  hospital. 
Indeed,  the  disease  prevailed  in  the  most  whimsical  manner, — 
now  existing  extensively  and  severely,  and  then  disappearing, 
and  as  suddenly  reappearing.  M.  T.  is  decidedly  opposed  to  the 
doctrine  of  its  being  contagious. 

And,  with  respect  to  the  influence  or  agency  of  labour  itself,  in 
producing  this  disease,  it  would  appear  from  the  testimony  of  all 
the  writers  on  puerperal  fever,  and  in  this  M.  Tonnelle  agrees, 
that  a  difficult  delivery  has  no  greater  agency  in  the  production 
of  this  fever,  than  the  most  easy  or  the  most  natural.  All  that 
appears  to  be  necessary  to  its  appearance  is  the  emptying  of  the 
uterus;  and  even  this  is  not  always  essential  to  its  production,  as 
instances  have  been  recorded,  where  this  fever  manifested  itself 
before  delivery.1  Besides,  the  male  is  unquestionably  liable  to 
peritoneal  inflammation  as  well  as  the  female;  and  when  it  occurs 
in  them,  the  same  general  phenomena  present  themselves.  Thus, 
Dr.  Armstrong,  p.  2,  assures  us,  "it  does  not  seem  to  depend 
upon  the  difficulty  of  labour,  for  in  most  of  the  women  in  whom 
it  occurred,  parturition  was  remarkably  easy,  and  the  placenta 
was  cast  off  after  a  proper  interval,  and  without  more  than  usual 
pain.  Nor  was  the  lochial  discharge,  before  the  attack,  in  any 
way  apparently  affected." 

Mr.  Hey  says,  p.  21,  "It  is  somewhat  remarkable,  that  I  have 
scarcely  known  an  instance  in  my  own  practice,  of  this  disease 
coming  on  after  a  preternatural  labour.  I  do  not  mean  to  imply 
that  such  cases  were  more  exempt  from  it  than  others,  but  so  it 
happened ;  and  the  fact  shows  that  it  was  independent  of  any  thing 
untoward  in  the  labour.  It  has,  on  the  contrary,  most  frequently 
occurred,  within  the  compass  of  my  experience,  after  the  most 
easy  and  natural  labours." 

But  Dr.  Clarke  seems  inclined  to  a  contrary  opinion,  though 
not  exactly  satisfied  with  his  own  sentiments.  He  observes, 
"For  some  reason  or  other,  there  seems  to  be  a  great  aptitude  in 
the  peritoneum  to  be  inflamed  in  women  after  delivery,  so  that 
causes  applied  to  the  body,  which  generally  have  a  tendency  to 
excite  inflammation  of  internal  parts,  seem  to  be  peculiarly  di- 

1  A  case  of  this  kind  occurred  lately.  A  lady  was  delivered  at  6  o'clock,  P.  M ., 
of  a  six  months'  child;  she  became  extremely  ill  by  the  next  morning:,  all  the 
sad  signs  of  puerperal  fever  declaring  themselves  :  she  died  at  3  o'clock,  P.  M.,  of 
the  same  day — that  is,  twenty-three  hours  after  delivery.  It  was  the  opinion  of 
Dr.  James,  who  saw  the  patient  in  consultation  with  Dr.  Moore,  that  the  fever  had 
commenced  before  he  saw  her — the  pulse,at  his  first  visit,  being  extremely  frequent. 
Her  labour  was  sufficiently  easy  for  a  premature  delivery;  but  the  patient  sank 
rapidly  until  the  moment  of  death.  When  I  saw  her,  (9  o'clock,  A.  M.,  fifteen 
hours  after  the  birth  of  the  child,)  she  was  nearly  without  pulse,  though  she  re- 
•  tained  her  senses;  the  abdomen  was  much  swollen,  and  extremely  distended — she 
died  six  hours  after.  I  am  of  opinion  that  this  was  an  instance  of  inflammation 
of  the  peritoneum  preceding  delivery. 

23 


354  PUERPERAL  FEVER. 

rected  in  their  operation,  to  this  part,  during  the  time  of  child- 
bed. Hence  this  disease,  (the  inflammation  of  the  peritoneum,) 
is  very  frequent,  and  has  been  also  called  puerperal  fever." 

"  It  has  been  conceived,  that  this  predisposition  might  depend 
upon  some  change  in  the  state  of  these  parts,  or  of  the  cavity  of 
the  abdomen,  succeeding  to  the  act  of  labour,  or  the  contraction 
of  the  uterus.  Yet  it  seems  not  to  be  conformable  to  the  wisdom 
of  nature,  to  construct  parts  so  that  the  circumstances  to  which 
they  must  necessarily  be  exposed  in  a  state  of  health,  should  either 
prove  a  predisponent,  or  an  immediate  cause  of  disease.  More- 
over, the  alteration  of  the  state  of  the  cavity  of  the  abdomen  is  so 
frequent  an  occurrence,  and  this  complaint  is  comparatively  so 
uncommon,  that  it  is  hardly  credible  that  so  many  should  escape, 
and  so  few  be  liable  to  its  influence. 

"In  some  cases,  the  pressure  made  by  the  child's  head,  in 
entering  the  pelvis,  against  the  peritoneum,  either  covering  the 
cervix  uteri,1  or  the  bladder,  may  predispose  to,  if  it  does  not 
actually  produce  the  disease ;  and  I  believe  it  is  often  an  occa- 
siona-1  cause.  It  may  be  said,  that  this  also  would  more  frequently 
produce  the  disease,  than  we  find  in  fact  that  it  does.  But,  on 
the  other  hand,  it  should  be  remembered,  that  it  is  only  in  cases 
where  the  head  is  comparatively  large,  that  so  great  a  degree  of 
pressure  can  happen,  as  to  occasion  the  disease.  Where  the  head 
is  small,  in  proportion  to  the  upper  aperture  of  the  pelvis,  or  is 
of  the  usual  size,  any  violent  degree  of  pressure  can  hardly  take 
place,  which  is  the  reason  why  the  disease  does  not  occur  after 
every  labour."  Essays,  p.  81. 

Now,  the  hypothesis  of  Dr.  Clarke  is  contradicted  by  almost 
every  other  writer ;  for  they  declare,  that  the  severity  of  the  act 
of  parturition  has  no  agency  in  producing  the  disease;  and  Dr. 
Denman  informs  us,  that  "Women  are  certainly  not  attacked  so 
often  with  this  fever  after  difficult  labours."  Again,  were  this 
a  cause,  it  should  be  an  ever-acting  one;  yet,  in  this  country,  the 
disease  is  scarcely  known,  though  the  females  of  it  have  their 
share  of  children,  whose  heads  are  of  full  size,  and  which  exert 
as  strong  a  pressure  upon  the  upper  aperture  of  the  pelvis,  and 
consequently  compress  the  peritoneum  as  certainly  and  as  power- 
fully, as  in  England,  or  other  portions  of  Europe. 

We  might  readily  multiply  authorities  to  prove  this  curious 
fact ;  and  from  its  importance  it  should  challenge  the  attention 
of  the  physician  to  an  investigation  of  the  cause  of  it ;  for  we  are 
not  altogether  satisfied  with  the  explanation  that  Dr.  Denman 
gives  of  this  singular  exemption;  namely,  "Because  of  the  par- 
ticular care  with  which  they  are  then  managed."  Were  this  the 

1  Dr. Clarke  has  committed  a  little  mistake  in  his  anatomy;  the  cervix  uteri  is 
not  covered  by  the  peritoneum;  it  is  only  the  body  and  fundus  that  derive  a  coat 
from  this  membrane. 


PUERPERAL    FEVER.  355 

cause  alone,  it  would  be  easy  to  arrest  the  progress,  or  at  least 
to  mitigate  the  violence  of  this  malady,  by  bestowing  the  same 
attentions ;  especially  upon  those  who  have  easy  labours,  while 
the  disease  was  ravaging  as  an  epidemic.  Indeed,  it  would  seem 
that  the  public  had  some  right  to  expect  a  practical  illustration 
of  the  suggestion  from  the  author  of  it ;  and  we  truly  regret 
that  he  had  not  turned  his  attention  to  it. 


c.   Of  Prophylactics. 

It  is  true,  there  appears,  from  the  practice  of  some,  a  founda- 
tion for  the  opinion  just  named  above  ;  so  far,  at  least,  as  certain 
medical  treatment  comprises  that  peculiar  care  bestowed  upon 
women  who  have  had  laborious  labours,  alluded  to  by  Dr.  Den- 
man  ;  for  Dr.  Gordon  informs  us  that  when  the  puerperal  fever 
raged  as  an  epidemic  at  Aberdeen,  a  bolus  composed  of  calomel 
and  jalap,  given  in  the  morning,  the  day  after  delivery,  either 
prevented  the  disease  entirely,  or  answered  the  good  purpose  of 
anticipating  the  cure  before  the  attack. — Treatise  on  Puerperal 
Fever,  p.  100. 

This  must  certainly  have  been  a  most  consoling  fact  to  the 
physician,  and  a  most  important  discovery  to  the  afflicted,  or 
those  liable  to  be  afflicted ;  since  a  sure  prophylactic  was  at  hand, 
or  a  remedy  in  waiting,  which  was  capable  of  disarming  this 
terrible  malady  of  its  dangers.  The  only  matter  of  surprise  is, 
that  after  this  discovery  we  should  have  heard  any  more  of  the 
dangers,  or  even  of  the  occurrence  of  puerperal  fever ;  for  if  the 
value  of  the  remedy  had  been  really  as  great,  as  the  eulogium 
passed  upon  it  declared  it  to  be,  we  ought  not. 

Mr.  Hey  has  furnished  us  with  his  experience  of  the  use  of 
this  remedy  :  he  says,  "  In  every  case  of  accouchement,  it  was  my 
practice  to  give  a  purgative  on  the  day  succeeding  the  delivery; 
which,  if  it  did  not  prevent  the  disease,  afforded  some  advantage 
in  its  cure,"  p.  154.  Now,  as  Mr.  Hey  has  not  given  us  the 
proportions  of  success  of  this  plan,  we  can  only  conjecture,  that 
neither  its  prophylactic,  nor  its  sanative  powers,  could  have  been 
very  great;  since  he  constantly  was  acquiring  patients,  some  of 
which  he  lost.1  Nor  does  it  appear,  from  the  history  of  his  cases, 
that  those  who  got  well  were  indebted  to  the  anticipating  purga- 
tive alone,  as  blood-letting  and  farther  purging  were  constantly 
had  recourse  to. 

From  all  we  can  learn  from  the  testimony  of  Dr.  Gordon  him- 

1  Indeed,  Mr.  Hey  informs  us,  immediately  after,  p.  155,  that  "some  of  th? 
worst  cases  in  his  practice  occurred  .after  an- excessive  operation  of  the  purga- 
tive." 


356  PUERPERAL    FEVER. 

<£. 

self,  and  from  Mr.  Hey,  who  followed  his  practice,  it  does  not 
appear  that  the  plan  under  consideration  deserves  the  sweeping 
encomium  bestowed  upon  it  by  its  inventor;  that  it  was  highly 
proper  and  very  useful,  we  have  every  disposition  to  believe ;  but 
that  it  ever  prevented  the  disease,  we  very  much  doubt.1  Indeed 
it  would  be  extremely  difficult  to  ascertain  when  it  did  prevent 
the  onset  of  this  disease ;  for  the  fact  amounts  but  to  this  nega- 
tive ;  that  some  of  the  women  who  took  it  escaped  the  disease ; 
but  this  is  no  proof  that  the  calomel  and  jalap  prevented  it ;  for 
it  is  not  fair  to  presume  that  every  newly  delivered  woman  would 
have  had  puerperal  fever. 

Besides,  weVe  this  power  of  preventing  the  onset,  or  of  abating 
the  force,  granted  to  the  calomel  and  jalap,  it  still  leaves  the  fact 
unexplained,  of  women,  who  must  have  had  laborious  labours, 
being  less  liable  to  this  disease ;  since,  agreeably  to  the  practice 
of  both  Dr.  Gordon  and  Mr.  Hey,  every  newly  delivered  woman 
was  treated  alike,  as  regards  the  exhibition  of  the  purgative : 
yet,  those  who  had  easy  labours  were  more  certainly  liable  to 
puerperal  fever  than  those  who  had  difficult  times. 

From  all  this,  it  would  appear  that  the  subject  is  still  open  for 
inquiry;  and  we  would  earnestly  recommend  it  to  those  whose 
practice  will  furnish  them  with  opportunities  to  inquire  into  the 
fact,  and  endeavour  to  discover  the  cause  why  a  tedious  and  pro- 
tracted labour  should  be  any  way  instrumental  in  diminishing 
the  liability  to  puerperal  fever.  For  we  may  well  ask  how  it  is, 
that  long  suffering,  and  very  certainly,  lesion  of  some  kind,  and 
to  various  extents,  should  diminish  the  predisposition  of  this  dis- 
ease, or  abate  the  force  of  the  exciting  causes ! 

Will  a  slight  inflammation  of  the  proper  substance  of  the  ute- 
rus, and  of  the  vagina,  which  follow  almost  necessarily  as  a  con- 
sequence of  a  long-protracted  or  preternatural  labour,  interrupt 
the  tendency  to  peritoneal  inflammation  ?  Is  this  rendered  pro- 
bable by  other  facts  relative  to  this  disease  which  are  certainly 
no  less  singular,  namely,  that  "not  one  instance  has  been  ob- 
served, of  any  woman,  who  had  an  abscess  in  the  breast,  being 
attacked  with  this  fever ;  nor  of  any  who,  in  consequence  of  their 
labour,  had  such  an  affection  of  the  bladder  as  to  occasion  a  sup- 
pression of  urine?"2  Denman,  Introd.  Francis's  Ed.  p.  574. 

1  Mr.  Hunter  long  since  taught  us  that  we  may  cure  a  disease,  but  that  we 
cannot  destroy  a  predisposition.  Even  the  anticipating  purging  cannot  always 
be  proper,  if  carried  to  any  considerable  extent.  We  see  this  illustrated  in  the 
practice  of  Mr.  Hey,  just  alluded  to ;  for  the  powerful  operation  of  a  cathartic  may 
be,  and  doubtless  is,  sometimes,  the  exciting  cause  of  the  disease. 

'  We  do  not  mean  that  these  facts  should  be  taken  for  more  than  they  are 
worth;  for  we  are  aware  that  different  explanations  may  be  given  of  them  ;  for, 
of  the  first  it  may  be  said,  that  the  woman  who  lives  free  from  the  disease  long 
enough  to  have  milk  secreted,  and  an  abscess  to  form,  most  probably  had  no  pre- 
disposition to  the  disease,  and  would  have  escaped  the  fever,  without  the  abscess  ; 


PUERPERAL    FEVER.  357 

'**  '¥* 

But  notwithstanding  the  powers  of  a  mercurial  purgative  have 

been  in  our  opinion  rather  overrated,  it  is  every  way  certain  that 
it  has  been  highly  useful ;  we  should,  therefore,  from  both  facts 
and  analogy,  recommend  the  adoption  of  the  plan  first  suggested 
by  Dr.  Gordon,  of  purging  briskly  at  the  end  of  the  first  eighteen 
or  twenty  hours,  or  earlier,  after  delivery,  whenever  there  was 
a  tendency  in  puerperal  fever  to  become  epidemic,  or  where  spo- 
radic cases  were  more  than  ordinarily  frequent. 


••" 


d.  Of  the  Seat  of  the  Disease,  and  its  proximate  Cause. 


Post  mortem  examinations  have  satisfactorily  shown  puerperal 
fever  to  consist  in  peritoneal  inflammation.  This  inflammation 
does  not  confine  itself  to  any  one  portion  of  this  membrane.  The 
mesentery,  omentum,  the  liver,  the  mesocolon ;  in  a  word,  every 
portion  of  the  abdominal  contents  may  be  the  seat  of  this  in- 
flammation ;  nay,  even  the  pleura  and  lungs  have  been  found  in- 
flamed ;  and  we  have  shown  by  the  tables  of  M.  Tonnell6  that 
the  whole  of  the  uterine  system  may  be  involved,  even  to  the 
very  vessels  of  these  parts  themselves,  as  the  veins,  lymphatics, 
&e. 

Before  death,  it  is  not  uncommon  for  this  inflammation  to  ter- 
minate in  effusion ;  hence  the  immense  quantity  which  is  some- 
times found  within  the  abdomen ;  and  perhaps  an  evidence  of 
some  peculiarity  of  the  lining  of  this  cavity,  since  no  other  serous 
membrane  pours  out  an  equal  quantity  in  the  same  time ;  nor 
does  equal  danger  attend  the  inflammation  of  them. 

Mr.  Cruikshank  informs  us  that  he  has  "taken  away  often 
forty  or  sixty  pints  of  water,  which  had  accumulated  in  the  ca- 
vity of  the  abdomen,  in  the  few  days  the  peritoneal  inflammation 
had  lasted,  during  the  usual  species  of  child-bed  fever."  On  the 
absorbents,  p.  11(5. 

Dr.  Clarke  says,  "  The  first  thing  which,  in  the  greater  number 
of  instances,  (of  dissection,)  presents  itself,  is  a  collection  of  fluid 
in  the  general  cavity  of  the  abdomen,  sometimes  very  large  in 
quantity,  inasmuch  as  I  have  often  absorbed,  by  means  of  a 
sponge,  several  pints  of  it."  Essays,  p.  135. 

When  effusion  is  extensive,  the  existence  of  a  previous  inflam- 
mation is  less  evident:  this  has  led  some  to  conclude,  that  this 
effusion  was  not  the  effect  of  active  inflammation ;  but  rather  the 
result  of  a  certain  disposition  of  the  vessels  of  the  parts  affected, 
essentially  different  from,  an  inflammatory  action. 

and,  that  the  abscess  was  only  an  evidence  of  this  want  of  disposition,  and  not 
of  its  being  prophylactic.  Of  the  other,  it  may  be  said  that  the  freedom  from  this 
fever  should  be  referred  to  the  tedious  and  painful  labour  of  which  the  suppression 
of  urine  was  a  consequence;  and,  therefore,  that  this  symptom  should  not  be  con- 
sidered as  having  any  agency  in  procuring  the  exemption. 


358  PUERPERAL    FEVER. 

*l     ' 

It  is  easy  to  refine  too  much,  and  nowise  difficult  for  a  sturdy 
polemic  to  deny  the  force  of  the  most  obvious  facts.  What  but 
the  resolution  of  inflammation  yields  such  a  quantity  of  fluid  as 
is  found  after  puerperal  fever?  what  but  inflammation  giving  out 
coagulable  lymph  will  account  for  the  interstices  of  the  intestines 
being  filled  up;  their  surfaces  covered;  and. their  various  convo- 
lutions connected  in  masses?  what  but  an  inflammation,  and  that 
of  the  most  active  kind,  will  give  rise  to  such  an  acceleration  of 
pulse;  such  immoderate  heat;  such  intense  pain;  such  exquisite 
soreness,  as  almost  constantly  combine  in  the  puerperal  fever? 
In  a  word,  we  must  repeat,  what  other  condition  of  the  blood 
vessels,  than  inflammation,  induces  them  to  give  out  so  suddenly 
and  so  excessively  their  fluids?  Besides,  inflammation  of  the 
peritoneum  from  other  causes,  is  known  to  terminate  in  large 
effusions  within  the  abdominal  cavity:  the  rupture  of  the  uterus, 
if  the  woman  should  not  die  too  soon,  is  always,  we  believe,  ac- 
companied by  a  large  effusion. 

Now,  it  is  a  fact,  very  well  ascertained,  indeed  we  had  almost 
said,  not  disputed,  that  when  the  vessels  of  an  inflamed  surface 
proceed  to  effusion,  there  is  an  immediate  reduction  of  that  in- 
flammation; nay,  sometimes,  a  complete  removal  of  it;  so  much 
so  is  this  occasionally  the  case,  that  disappointment  has  followed 
the  search  for  it,  where  there  previously  existed  every  evidence 
but  ocular  demonstration. 

Had  Dr.  Clarke  been  sufficiently  acquainted  with  this  fact,  or 
permitted  it  to  have  had  its  full  weight,  we  would  scarcely  have 
consented  to  have  agitated  the  following  questions: 

I.  "Does  the  fever  in  a  puerperal  woman  dispose  the  perito- 
neum to  effuse  the  fluid,  which,  being  of  a  coagulable  nature, 
forms  a  coat  on  different  surfaces? 

II.  "Does  an  inflammation  of  a  small  part  dispose  the  whole 
of  the  peritoneum  to  throw  out  the  coagulating  fluid? 

III.  "Does  the  inflammation  precede  or  follow  the  effusion? 
If  the  latter,  is  the  inflammation  excited  by  a  stimulating  quality 
of  the  matter  itself?  or  lastly,  are  the  fever,  the  inflammation, 
and  the  effusion  of  fluid,  entirely  independent  of  each  other,  as 
to  cause  and  effect,  and  are  they  only  parts  of  one  whole,  which 
is  a  disease  sui  generis?"  p.  157. 

If  the  first  question  mean,  as  we  presume  it  does,  that  the 
fever  in  question  may  so  act  upon  the  peritoneum  as  to  force  it 
to  effusion  without  any  intermediate  condition,  as  inflamma- 
tion, we  would  answer  it  in  the  negative,  and  for  the  following 
reasons: — 

1st.  Because  we  know  of  no  instance  of  an  effused  fluid  re- 
sembling the  one  found  in  the  cavity  of  the  abdomen,  without  the 
intervention  of  some  altered  condition  of  the  parts  concerned; 
nor  of  any  other  fluid,  to  the  same  extent  in  the  same  space  of 


PUERPERAL   FEVER.  359 

time.  In  cases  of  large  collections  of  water  in  cavities,  as  in  as- 
cites,  &c.,  it  is  always  very  gradual;  and  seems  to  be  rather 
owing  to  the  defect  of  absorption,  than  to  an  increase  of  deposi- 
tion ;  though  in  some  instances  there  is  strong  reason  to  believe 
it  to  be  the  result  of  a  previous  inflammatory  action. 

2dly.  Because,  we  know,  when  serous  effusions  take  place  in 
other  portions  of  the  body,  that  they  are  always  preceded  by 
inflammation ;  as  in  hydrothorax,  hydrocele,  hydrocephalus,  &c. ; 
and  when  they  take  place  upon  the  surface  of  the  body,  as  from 
blisters,  burns,  or  scalds,  we  know  that  inflammation  existed  be- 
fore the  effusion ;  nor  do  we  ever  see  it  but  as  the  result  of  highly 
excited  vessels. 

3dly.  Because,  in  all  instances  of  the  resolution  of  inflamma- 
tion, by  effusion,  a  serous  fluid  is  thrown  out;  and  when  thrown 
out,  the  inflamed  surface  which  yielded  it  is  always  relieved  from 
the  excitement,  either  in  part,  or  altogether. 

II.  The  second  question  we  would  answer  also  in  the  negative ; 
and  for  reasons  that  might  be  in  part  collected  from  the  answers 
to  the  first;  for,  1st,  if  the  inflammation  of  a  portion  of  the 
peritoneum  could  excite  portions  to  effusion  which  are  not  in- 
flamed, it  would  of  course  be  admitting,  that  effusion  can  take 
place  without  inflammation,  or  that  a  sound  part  can  perform 
the  functions  of  a  diseased  one;  a  position  we  must  entirely 
deny.     2dly.  Were  this  admitted,  it  would  be  supposing  that  an 
inflamed  surface,  and  one  which  is  not  inflamed,  would  yield  the 
same  fluid,  which  is  contrary  to  all  experience. 

III.  To  the  third  query  and  consequences,  we  would  say,  that 
inflammation  always  precedes  effusion;  and  that  the  fever  is  but 
the  result  of  the  local  inflammation. 

1.  Because  a  sense  of  soreness  and  tenderness  is  always  ex- 
perienced in  some  one  portion  of  the  abdominal  cavity,  before 
the  fever  is  well  formed ;  and  in  the  accounts  we  have  of  this 
fever,  as  it  appeared  in  the  Hotel  Dieu,  we  are  told  that "  after 
the  escape  of  the  waters,  the  uterus  became  dry,  rigid,  painful, 
and  swelled,  and  that  the  lochia  did  not  flow  as  usual." 

2.  Because  the  excitement  of  the  arterial  system  keeps  pace 
with  the  inflammation  of  the  peritoneum. 

3.  Because  fevers  from  other  causes  have  no  tendency  to  pro- 
duce peritoneal  inflammation ;  as  milk  fever,  the  weed,  or  even 
erysipelas;  consequently,  that  there  must  be  a  disposition  in  the 
peritoneum  to  take  on  inflammation  after  delivery.1 

*  We  may  include,  with  much  propriety,  under  the  head  of  delivery,  those  in- 
stances of  abortion,  which  have  been  followed  by  puerperal  fever.  Dr.  Hull  says, 
"  It  sometimes  attacks  women  who  have  suffered  an  abortion,  or  who  have  been 
prematurely  delivered,  as  well  as  those  who  have  gone  their  full  time  of  utero- 
gestation."  Treatise  on  Phlegm.  Dolens,  p.  SW8. 

Mr.  Hey  also  informs  us,  that  he  met  with  two  cases  of  puerperal  fever  after 
abortion,  p.  27.  See  note  to  page  341). 


360  PUERPERAL    FEVER. 

4.  Because,  whatever  excites  inflammation  in  the  peritoneum, 
by  local  irritation,  as  tapping,  sometimes;  rupture  of  the  uterus ; 
inflammation  of  the  proper  substance  of  the  uterus,  when  it  in- 
volves this  membrane,  &c.,  but  not  until  then ;  extraneous  sub- 
stances passing  from  the  stomach  and  bowels  into  the  cavity  of 
the  abdomen;  punctures  or  wounds  in  this  cavity,  give  the  same 
phenomena;  proving  beyond  doubt  that  when  this  membrane  is 
indisputably  the  seat  of  inflammation,  the  system  at  large  sym- 
pathizes in  the  same  manner  as  in  puerperal  fever. 

From  these  facts,  and  others  developed  by  dissection,  we  have 
no  hesitation  to  declare,  that  puerperal  fever  is  an  inflammation 
of  the  peritoneum. 

This  inflammation  always  terminates  in  effusion  or  suppuration 
before  death ;  and  never,  or  but  very  rarely,  in  gangrene,  so  far 
as  dissections  have  yet  discovered.1  Dr.  Clarke  says,  p.  135,  that 
"the  inside  of  the  uterus,  or  of  the  intestines,  has  not  been  found 
inflamed  in  any  of  those  whom  I  have  had  an  opportunity  of  ex- 
amining after  death ;  much  less  have  I  found  any  signs  of  gan- 
grene or  mortification."  These  are  curious  facts  as  regards  this 
disease ;  and  they  are  particularly  valuable  as  coming  from  so 
veracious  and  candid  a  man  as  Dr.  Clarke;  and  completely  esta- 
blishes Biehat's  doctrine  of  the  tissues ;  the  disease  which  killed 
the  patients  he  examined  was  "the low  fever  of  child-bed,"  and 
had,  agreeably  to  him,  a  strong  tendency  to  "putridity,"  as  his 
practice  declares,  and  as  on  one  occasion  he  avows,  p.  115. 

For  he  expressly  says,  that  "all  the  medicines  which  have 
been  employed  with  a  view  to  the  diminution  of  an  inflammation, 
have,  in  the  course  of  my  experience,  failed  in  curing  the  dis- 
ease. It  became,  therefore,  next  an  object,  to  try  whether  such 
as  have  a  tendency  to  support  the  strength  and  diminish  the 
irritability,  would  be  attended  by  better  success. 

1  Dr.  Fordyce  intimates,  from  the  character  of  the  symptoms,  and  the  analogy 
of  the  circumstances,  that  we  might  suspect  gangrene  sometimes ;  but  there  is  no 
mention  that  this  has  ever  taken  place.  He  says,  that  "  the  suppuration  is  very 
different  in  its  effects  from  the  suppuration  which  takes  place  in  other  inflamma- 
tions :  for  the  pain  goes  off  suddenly,  and  even  the  soreness  sometimes,  but  the 
tumefaction  continues;  the  pulse  becomes  more  frequent;  the  strength  is  more 
depressed,  and  the  patient  is  cut  off  in  from  six  to  twenty-four  hours  afterwards ; 
so  that  from  the  symptoms  it  might  be  supposed,  that  gangrene  had  taken  place  in 
these  cases."  Hull,  p.  234. 

And  Dr.  Leake  says,  in  Case  VIII.  p.  197,  "  On  opening  the  body,  the  inferior 
lateral  portion  of  the  omentum  was  found  much  inflamed ;  but  the  greater  portion 
was  destroyed  by  suppuration.  Case  IX.  The  greater  part  of  the  omentum  was 
suppurated ;  the  remaining  portion  much  inflamed,  &c.  Case  XIII.  Great  part 
of  the  omentum  was  destroyed,  and  converted  into  matter;  what  remained  had 
become  gangrenous:"  this  is  the  only  mention  made  of  gangrene  by  Dr.  Leake, 
and  the  part  being  in  this  condition,  must  have  been  the  result  of  previous  inflam- 
mation, but  which  had  not  relieved  itself  by  effusion,  and  thus  died.  For  he 
makes  no  mention  of  a  fluid  in  the  abdomen,  but  declares  that  that  portion  of 
the  omentum  which  is  inserted  round  the  great  curvature  of  the  stomach  was 
considerably  inflamed. 


• 


PUERPERAL    FEVER.  361 

"  As  soon,  then,  as  any  very  considerably  increased  frequency 
of  the  pulse  is  discovered,  I  believe  that  it  is  right  to  begin  im- 
mediately with  exhibiting  the  Peruvian  bark  very  freely,  and  in 
as  large  quantities  as  the  stomach  will  bear,"  &c.,  p.  162.  Now, 
the  mode  of  treatment  here  pointed  out  declares  the  tendency 
to  the  typhoid,  (or  putrid)  state,  if  you  please;  yet  there  was 
neither  mortification  nor  gangrene  discoverable  in  any  portion 
of  the  cavity  of  the  abdomea.  Yet  the  phlegmonous,  the  ery- 
thematous,  and  erysipelatous  inflammations,  when  violent,  will 
each  terminate  sometimes  in  gangrene  or  sphacelus. 

Dr.  Clarke  has  endeavoured  to  prove  that  the  inflammation  of 
the  peritoneum  of  a  puerperal  woman,  and  "  the  low  fever  of 
child-bed,"  are  essentially  different  diseases.  But  he  has  not 
been  successful  in  this  attempt,  as  may  readily  be  proved  by 
comparing  the  symptoms  he  details  as  belonging  to  each,  as 
well  as  the  post  mortem  appearances,  making  allowances  for 
seasons,  locations,  epidemic  constitution  of  the  air,  and,  conse- 
quently, the  type  which  these  will  impose  upon  certain  parts  of 
the  character  of  the  disease.1 

In  both  of  the  diseases  which  he  describes,  (Essays,  sect.  III. 
p.  81,  and  Sect.  VI.  p.  102,)  the  peritonitic  inflammation,  and 
the  puerperal  fever,  attack  at  the  same  period  after  delivery :  they 
are  both  preceded,  sometimes  by  rigour,  and  sometimes  not. 
Both  have  a  soreness,  tenderness,  and  distention  of  the  abdomen; 
in  both  the  pulse  is  accelerated  in  a  remarkable  degree,  very 
soon  after  the  tenderness  of  the  abdomen  is  experienced.  In 
both,  the  secretion  of  the  milk  is  interrupted,  if  it  has  not  been  se- 
creted ;  or  if  begun  to  be  formed,  it  is  immediately  suspended. 
In  both  does  the  woman  discover  indifference  to  her  offspring;  in 
both  is  the  state  of  the  stomach,  the  appearance  of  the  tongue, 
the  condition  of  the  brain,  the  feel  of  the  skin,  &c.,  the  same;  or, 

1  Dr.  Clarke  says,  "It  is  very  well  known,  that  during  the  strong  exertions  of 
labour,  every  woman  suffers  a  kind  of  temporary  fever;  or,  in  other  words,  the 
action  of  the  heart  and  arteries  is  very  considerably  accelerated.  Now,  if  this 
should  happen  to  a  woman  under  the  influence  of  the  causes  adverted  to  above, 
(namely,  the  epidemic  constitution  of  the  air,  &c.,)  and  if,  under  these  circum- 
stances, any  occasional  cause  of  fever  should  occur,  such  as  exposure  to  cold,  or 
infection,  the  disease  thence  arising  will  be  most  susceptible  of  that  type  to  which 
the  system  has  the  greatest  aptitude,"  p.  152.  And  to  show  his  entire  belief  in 
the  power  of  the  air,  he  says,  the  epidemic  disposition  of  the  season  must  likewise 
always  be  taken  into  the  account ;  otherwise,  under  these  circumstances  (of  pre- 
disposition,) "  the  same  disease  would  always  arise,  if  the  same  occasional  causes 
were  applied,  which  is  not  the  case,"  p.  151.  He  farther  adds,  p.  15J,  "  Now  the 
nature  of  the  epidemic  constitution,  which  had  prevailed  at  the  time  when  this 
disease  was  prevalent  at  Paris  in  174G,  and  in  London  in  17rt7  and  1788,  was  a 
disposition  to  disease  of  debility;  with  such  a  predisposition,  if  any  diseased  state, 
especially  fever,  should  appear  in  a  parturient  woman,  it  would  almost  certainly 
put  on  that  character  which  the  preceding  history  of  this  disease  fully  justifies." 
Now  it  is  evident,  that  in  such  cases  the  nature  of  the  disease  is  not  changed,  it 
is  only  the  character  of  the  type  that  is  affected. 


362  ^PUERPERAL    FEVER. 

at  least,  they  are  without  a  marked  difference  in  any  respect. 
In  both  does  the  pulse  increase  in  rapidity,  as  the  soreness  and 
distention  of  the  abdomen  increase ;  and  both  have  the  same  at- 
tending symptoms,  and  the  same  period  for  their  fatal  termina- 
tions. Both  have  the  same  kind  of  effusions. 

The  differences  observed  in  post  mortem  examinations  are,  in- 
deed, very  trifling;  in  the  inflammation  of  the  peritoneum,  "the 
appearances,  upon  examining  th^  bodies  of  women  who  have 
died  of  the  disease,  have  been  those  of  inflammation  of  this  mem- 
brane, covering  the  different  viscera.  Upon  the  whole,  that  of 
the  neck  of  the  uterus  and  bladder  will  be  found  more  generally 
inflamed  than  of  other  parts;  nevertheless,  there  is  no  part  on 
which  inflammation  is  not  sometimes  found.  The  surface  of  the 
stomach,  liver,  spleen,  omentum,  great  and  small  intestines,  ute- 
rus, the  internal  peritoneal  lining  of  the  muscles  of  the  abdomen 
will,  in  their  turns,  or  altogether,  be  found  to  partake  of  the  dis- 
ease :  and,  as  far  as  my  experience  leads  me  to  judge,  no  part 
more  than  another."1 

"A  very  large  quantity  of  fluid  is  generally  collected  in  the 
cavity  of  the  abdomen,  resembling  serum  mixed  with  pus;  but  it 
differs  from  both  of  them  in  this  respect,  that  it  is  not  homoge- 
neous in  its  texture,  but  intermixed  with  portions  of  a  solid  mat- 
ter, resembling  pieces  of  the  same  solid  matter  as  is  found  on  the 
surfaces  of  the  peritoneum,  the  nature  of  which  will  be  more  par- 
ticularly taken  notice  of  hereafter,"  p.  88. 

Of  the  examinations  he  made  of  those  who  died  of  "the  low 
fever  of  child-bed,"  he  says,  "The  first  thing  which  presents  it- 
self is  a  collection  of  fluid  in  the  general  cavity  of  the  abdomen, 
sometimes  very  large  in  quantity ;  insomuch,  that  I  have  often 
absorbed  with  a  sponge  several  quarts  of  it.  It  is  of  the  same 
nature  with  that  which  I  have  described  in  a  former  section, 
(namely,  the  above,)  as  far  as  can  be  ascertained  by  its  sensible 
qualities.  There  is  something  very  remarkable  in  the  smell  of 
this  fluid,  which  is  peculiar  to  itself,  and  distinguishes  it  from  any 
other  fluid  which  I  have  ever  met  with  in  the  human  body,  either 
in  health  or  in  disease.2  Where  it  is  in  large  quantity,  all  the  sur- 

1  Walter  is  said  to  have  dissected  more  than  five  hundred  (a)  women  who  had 
died  in  child-bed.  He  constantly  found,  in  those  who  died  of  puerperal  fever,  the 
peritoneum,  throughout  its  extent,  smeared  with  a  pus-like  substance ;  but  never 
found  the  mucous  or  muscular  structure  implicated. — Med.  Chirur.  Journ.  vol. 
iv.  p.  420. 

1  Is  not  this  circumstance  absolutely  conclusive  of  the  identity  of  the  two  dis- 
eases ?  Does  not  this  peculiar  smell  of  the  extravasated  fluids  prove  the  sameness 
of  the  inflammation  which  yields  them?  and  do  not  the  various  seats  of  the  in- 
flammation establish  their  kindred  nature  ?  For  Dr.  Clarke  informs  us  it  was  not 
confined,  in  either  case,  to  any  one  particular  part. 

(a)  We  have,  at  a  venture,  changed  the  number  to  500  from  5000,  believing  there  must  have 
been  an  error  in  the  text  from  which  we  quoted. 


PUERPERAL    FEVER. 


faces  of  the  viscera,  and  of  the  peritoneum  generally,  will  be 
found  covered  with  a  crust  formed  of  a  solid  part  of  this  matter, 
resembling  coagulating  lymph.  Its  particles  cohere  but  slightly, 
so  that,  by  a  little  agitation,  it  will  mix  with  the  fluid  matter. 
The  parts  lying  under  this  coat  or  crust  are  not  always  inflamed.* 

If  there  be  any  interstices  between  the  intestines,  or  the  other 
viscera  of  the  cavity  of  the  abdomen,  they  are  frequently  filled 
with  large  masses  of  the  same,  making  an  accurate  cast  of  such 
interstices. 

"  The  quantity  of  fluid  extravasated,  and  of  the  solid  part  float- 
ing in  it,  or  incrusted,  is  prodigious  sometimes,  when  the  disease 
has  been  of  short  duration,  not  exceeding  two  or  three  days.  They 
seem,  also,  as  far  as  I  am  able  to  judge,  to  bear  no  proportion  to 
the  degree  of  inflammation,  or  the  extent  of  inflamed  surface; 
since  we  often  find  a  large  quantity  of  both,  where  the  redness  of 
any  surface  has  been  very  inconsiderable,  andby  no  means  general. 
In  most  instances,  there  has  been  some  slight  degree  of  inflam- 
mation in  some  part  of  the  cavity  of  the  abdomen ;  but  it  has  not 
been  confined  invariably  to  any  particular  part." 

"  Sometimes  the  peritoneal  surface  of  the  intestines,  sometimes 
of  the  liver,  and  sometimes  the  investing  membrane  lining  the 
muscles,  have  been  found  partially  inflamed;  but  I  have  scarcely 
ever  seen  any  extensive  degree  of  inflammation  in  any  case,  and 
in  some  I  could  hardly  say  that  there  was  any,"2  p.  135. 

Now,  the  only  difference  we  can  discover  from  the  histories  of 
the  dissection  of  the  two  diseases  is,  that  the  neck  of  the  uterus 
and  bladder  are  generally  more  inflamed  than  other  portions  of 
the  peritoneal  surface:  in  effcry  other  respect,  they  are  so  faith- 
fully alike,  as  not  to  raise  a  suspicion  of  a  difference.  It  is  true, 
that  Dr.  Clarke,  and,  perhaps,  others  who  may  have  embraced 
his  opinions,  might  insist  that  there  are  other  very  remarkable 
differences;  but  we  cannot  view  them  in  this  light;  since  the  ap- 
parent discrepancies  can  easily  be  accounted -for,  without  the  ne- 
cessity of  supposing  them  unrelated  to  each  other.  We  have 
marked  by  italics  the  points  of  resemblance. 

We  will  first  notice,  however,  the  coincidences  of  appearances ; 

1  Dr.  Clarke's  observation  only  amounts  to  this,  that  after  effusion  has  taken 
place,  redness  is  not  always  found;  but  this  happens  from  a  cause  familiar  to  every 
practitioner;  namely,  that  when  inflamed  vessels  effuse  serum,  they  become  re- 
lieved, and  the  redness  disappears. 

1  "We  have,  indeed,  been  told,  that  in  the  dissections  of  some  who  are  said  to 
have  died  of  this  disease  (puerperal  fever,)  no  appearances  of  inflammation  have 
been  discovered;  but  I  should  suspect,  that  in  such  cases  some  important  appear- 
ances had  been  overlooked,  or  that  error  had  been  committed  as  to  the  nature  of 
the  disease,  and  probably  in  its  treatment."— Denman,  Introd.  to  Mid.,  Francis's 
Ed.  p.  583. 

"Whatever  be  the  cause  of  puerperal  fever,  the  cause  of  death  is  the  same  in 
all  its  varieties;  namely,  abdominal  inflammation." — Gordon,  p.  117. 


364  PUERPERAL    FEVER. 

and  then  attempt  to  account  for  the  seeming  differences.  1st.  In 
both  cases,  the  extravasated  fluid,  agreeably  to  Dr.  Clarke's  own 
statement,  is  the  same;  as  he  says,  "it  is  of  the  same  nature" 
in  both  instances.  Now  let  us  ask,  is  it  probable  that  dissimilar 
diseases  of  the  peritoneal  surface  shall  produce  fluids  alike  in 
every  respect,  as  far  as  can  be  determined  by  their  sensible  or 
chemical  qualities  ?  and  especially  as  Dr.  Clarke  observes,  that 
"there  is  something  very  remarkable  in  the  smell  of  this  fluid, 
•which  distinguishes  it  from  every  other  fluid."  Does  not  this 
fact  satisfactorily  prove,  if  that  inflammation  of  the  peritoneum 
called  puerperal  fever  yields  a  fluid  of  particular  qualities  or  pro- 
perties within  the  abdominal  cavity;  and  if  a  fluid  of  precisely 
the  same  kind  is  found  in  the  abdomens  of  those  who  die  of  "  the 
low  fever  of  child-bed,"  that  the  same  action  must  have  yielded 
both,  and  that  they  must  be  one  and  the  same  disease?  We 
think  the  force  of  this  conclusion  is  irresistible. 

2.  In  the  inflammation  of  the  peritoneum,  Dr.  Clarke  says  the 
surfaces  of  all  the  viscera  in  their  turn,  or  altogether,  may  be  in- 
flamed ;  he  says,  that  precisely  the  same  thing  happens,  but  not 
to  the  same  extent,  in  "the  low  child-bed  fever:"  it  is  then  the 
degree  of  inflammation,  agreeably  to  this,  and  not  the  absence  of 
it,  in  t\\e  latter  instance,  that  constitutes  the  difference  of  the  two 
cases,  for  we  think  we  have  rendered  it  more  than  probable,  from 
the  nature  of  the  fluids  found  in  the  abdominal  cavity,  that  in 
both  instances  they  are  the  result  of  a  similar  inflammation. 
Having  cursorily  remarked  upon  the  coincidences  of  the  fevers, 
we  shall  attempt  to  account  for  their  seeming  discrepancies. 

I.  Dr.  Clarke  tells  us,  that  in  the  low  fever  of  child-bed,  a  coat 
most  probably  of  coagulating  lymph,  covers  the  whole  or  a  part 
of  the  abdominal  contents ;  but  the  parts  under  this  coat  or  crust 
are  not  always  inflamed;  whereas,  in  the  fever  from  peritoneal 
inflammation,  this  condition  is  obvious,  especially  about  the  neck 
of  the  uterus  and  bladder ;  and  no  crust  is  noticed. 

This,  at  first  sight,  might  lead  some  to  suppose  that  a  very 
material  difference  existed  between  the  two  diseases ;  and  espe- 
cially if  they  be  not  aware  that  a  number  of  causes  may  make  a 
difference  in  the  intensity  of  any  given  disease ;  but  especially  in 
one  so  liable  to  become  epidemic  as  puerperal  fever.  For  the 
sporadic  cases,  of  all  such  diseases  as  may  become  epidemic,  are 
milder  ;  and  consequently  more  manageable  than  when  they  be- 
come epidemic.1  If  this  be  so,  it  can  only  happen  from  the  spo- 
radic cases  acquiring  the  intensity  which  the  epidemic  constitu- 

'  This  fact  has  ever  been  notorious  in  our  yellow  fevers.  The  histories  of  this 
disease,  as  it  appeared  in  its  several  visitations  in  Philadelphia,  show  that  the  an- 
ticipating cases,  if  they  may  be  so  termed,  were  comparatively  mild,  and  that  the 
malignancy  increased  in  proportion  to  the  continuance  of  the  disease,  or  at  least 
until  the  type  was  modified  by  cool  weather  or  frost. 


PUERPERAL   FEVER.  365 

tion  of  the  air  gives  any  particular  epidemical  disease.  Thus, 
Dr.  Leake  says,  that  puerperal  fever  "will  always  be  found  most 
fatal  when  most  epidemical ;  that  is,  during  a  distemperature  of 
the  air." — Treatise  on  Child-bed  Fevers,  p.  73.  Mr.  Hey  says, 
"  I  am  persuaded  that  this  circumstance  (the  influence  of  the  air) 
is  deserving  of  the  greatest  attention ;  and  that  whoever  attempts 
to  cure  an  epidemic  puerperal  fever  by  such  means  as  are  com- 
monly sufficient  for  the  sporadic  cases,  will  find  himself  greatly 
disappointed  in  the  result,"  p.  13. 

It  is  to  be  remarked,  that  this  difference  between  a  sporadic 
and  epidemic  disease  is  not  confined  to  the  puerperal  fever ;  for 
it  is  incident  to  all  the  diseases,  as  we  have  said,  which  may  be- 
come epidemical.  This  has  frequently  been  experienced  in  the 
yellow  fever,  the  dysentery,  and  the  remittent  and  intermittent 
fevers  of  this  country. 

It  is  therefore  probable,  nay,  we  believe,  certain,  that  the  spo- 
radic puerperal  fever  might  furnish  the  description  Dr.  Clarke 
has  given  of  the  peritoneal  inflammation,  and  the  epidemical 
puerperal  fever  might  afford  the  appearances  recorded  of  "the 
low  fever  of  child-bed,"  and  yet  be  one  and  the  same  disease; 
that  is,  both  caused  by  peritoneal  inflammation. 

But  without  resorting  to  these  suggestions,  which  may  be  by 
some  looked  upon  as  gratuitous,  we  will  mention  a  fact  familiar 
to  every  body  who  has  paid  attention  to  epidemics,  which  is,  that 
the  reigning  disease  may  differ  very  essentially  in  type  at  the 
different  periods  of  its  visitations.  Thus,  no  two  yellow  fevers, 
as  epidemics,  were  precisely  alike  in  this  city.  The  fever  of 
1793  was  very  different  from  that  of  1798 ;  and  that  of  1797 
different  from  both,  as  regarded  the  conditions  of  the  system ; 
and  this,  consequently,  made  it  necessary  to  change  our  thera- 
peutical views.  Yet,  in  all  post  mortem  examinations,  they  were 
found  to  resemble  each  other  in  so  many  important  points,  as  not 
to  leave  a  doubt  of  the  identity  of  the  diseases. 

Besides,  an  epidemical  constitution  of  the  air  may  exert  an 
influence  upon  more  than  one  disease  at  the  same  time ;  and  this 
fact  gives  the  strongest  evidence  of  a  distemperature  of  the  air. 
Thus,  Dr.  Gordon  informs  us,  that  erysipelas,  and  the  puerperal 
fever,  "began  in  Aberdeen  at  the  same  time;  and  afterwards 
kept  pace  together;  they  both  arrived  at  their  acme  together, 
and  they  both  ceased  at  the  same  time."  Treatise  on  Puerperal 
Fever,  p.  50. 

Dr.  Clarke  says,  "  Inflammatory  diseases  had  been  extremely 
infrequent;  or,  if  they  occurred  at  all,  they  were  principally  of 
the  erysipelatous  kind.  Eruptive  diseases,  particularly  those 
which  are  attended  with  great  depression  of  strength,  had  at- 
tacked great  numbers  of  patients.  The  ulcerous  sore  throat, 
with  or  without  scarlatina,  had  been  very  general,  both  in  Lon- 


366  PUERPERAL  FEVER. 

don,  and  also  in  the  country  at  a  distance  from  the  capital. 
Most  of  the  fevers  had  been  of  the  low.  nervous,  and  malignant 
kind,  approaching  to  that  type  which  has  been  by  some  called 
putrid,"  p.  115. 

"About  the  same  period,  also,  in  some  situations  in  the  country, 
especially  in  low  marshy  places,  the  generality  of  patients  under 
inoculation  had  recovered  with  great  difficulty.  Abscesses  formed 
in  the  axillae ;  large  ulcers  and  sloughs  took  place,  both  there  and 
at  the  place  of  insertion  of  the  matter,"1  p.  116. 

Again,  "  The  stimulus  of  her  labour,  (the  woman  whose  case 
he  is  relating,)  brought  on  a  degree  of  fever,  which  degenerated 
in  consequence  of  the  nature  of  the  then  prevailing  epidemic 
constitution,  into  a  low  type,"  p.  150. 

Yet,  with  all  this  evidence  before  him,  Dr.  Clarke  insisted  on 
the  slight  difference  which  he  had  observed  between  the  sporadic 
puerperal  fever,  (for  such  were  the  cases  of  peritoneal  inflamma- 
tion which  he  describes,)  and  "the  low  fever  of  child-bed,"  which 
was  a  puerperal  fever,  or  an  inflammation  of  the  peritoneum,  in 
an  epidemic  form,  to  be  different  diseases ;  and  seriously  admo- 
nishes the  young  practitioner  not  to  mistake  the  one  for  the  other. 
Every  body  familiar  with  the  diversifying  influence  of  an  epi- 
demical constitution  of  the  air,  knows  the  variety  of  type  it  will 
force  the  same  disease  to  assume,  at  the  different  periods  of  its 
visitations,  or  even  in  different  situations.  Some,  who  have  not 
been  attentive  to  the  influence  of  the  cause  just  mentioned,  and 
who  neither  recognise  its  existence,  nor  acknowledge  its  power, 
have  been  led  into  serious,  and  we  had  nearly  said,  absurd  errors, 
on  the  subject  of  puerperal  fever.  Thus,  Dr.  Kirkland  supposes 
that  the  genuine  puerperal  fever  is  never  epidemic;  at  least  he 
says,  that  "the  puerperal  fever  which  has  been  observed  in 
hospitals,  is  owing  to  some  causes  peculiar  to  hospitals;"  and 
that  when  it  occurs  in  such  places,  "it  should  be  considered  as 
an  adventitious  disease,  happening  to  women  in  child-bed." — 
Treatise,  p.  73. 

When  we  consider  the  circumstances  under  which  females 
are  placed,  even  in  the  best  regulated  hospitals,  we  are  nowise 
surprised  that  the  puerperal  fever  should  be  more  common,  and 
more  fatal  to  them,  than  to  patients  in  private  life.  That  there 
may  be,  and  most  probably  are,  causes  in  hospitals,  which  pretty 
constantly  operate  in  such  a  manner  as  to  give  a  peculiar  type 
to  a  disease  similar  to  that  which  an  epidemic  constitution  of  the 
air  might  effect,  we  have  no  hesitation  to  believe ;  since,  in  such 
situations,  the  disease  is  not  only  more  common,  but  is  some- 

'Much  more  difference  will  be  perceived  between  tbe  small-pox  under  ordinary 
circumstances,  and  the  form  it  assumed  in  the  cases  just  stated  by  Dr.  Clarke, 
than  between  "  peritoneal  inflammation"  and  "  the  low  fever  of  child-bed,"  yet 
Dr.  C.  did  not  hesitate  to  call  both  "  small-pox." 


PUERPERAL    FEVER.  367 

times  exclusively  confined  to  them.  But  in  granting  this,  it  does 
not  do  away  the  possibility  of  its  prevailing  as  an  epidemic  else- 
where. 

Indeed,  the  history  of  this  disease  as  an  epidemic,  abundantly 
proves  that  the  situations  remote  from  hospitals,  or  even  from 
cities,  have  been  visited  by  this  fatal  malady.1  On  this  head  Mr. 
Hey  says,  that  "It  must  be  allowed  that  the  puerperal  fever  has 
occurred,  as  an  epidemic,  most  frequently  in  hospitals;  but  if  any 
proof  were  wanting  that  it  may  be  epidemical,  independently  of 
any  cause  peculiar  to  hospitals,  that  proof  is  abundantly  supplied 
by  the  instances  of  this  fever  which  have  occurred  at  Aberdeen 
and  Leeds;  where  it  was  not  confined  to  situation,  rank,  or  cir- 
cumstances ;  affecting  alike  the  rich  and  the  poor,  the  young  and 
the  old,  the  inhabitants  of  the  town  and  of  the  country,"  p.  12. 

Besides  we  are  quite  at  a  loss  to  comprehend  the  meaning  of 
Dr.  Kirkland's  appellation,  "the  genuine  puerperal  fever,"  if  a 
distinction  be  intended  by  it ;  for  a  fever  happening  to  a  lying-in 
woman  must  be  a  genuine  puerperal  fever,  if  the  peritoneum  be 
inflamed ;  or,  if  it  be  not  inflamed,  it  must  be  some  other  variety 
of  fever ;  therefore,  a  puerperal  fever  must  be  a  genuine  puer- 
peral fever,  or  it  is  no  puerperal  fever  whatever.  A  spurious 
puerperal  fever  cannot  exist :  for,  unless  the  peritoneum  be  in- 
volved in  inflammation,  there  is  no  propriety  in  the  title;  and  if 
it  be,  it  cannot  be  other  than  genuine. 

But  to  return,  Dr.  Clarke  says,  that  "the  parts  under  the  crust 
or  coat,"  (of  coagulable  lymph,)  "are  not  always  inflamed;" 
this  must  be  certainly  understood  to  declare,  that  they  generally 
are;  and,  if  they  generally  are,  the  appearance  of  inflammation 
must  produce  a  stronger  resemblance  to  the  peritoneal  inflamma- 
tion, than  he  appears  to  have  been  willing  to  admit.  Not  that 
we  consider  this  circumstance  essential  to  the  establishment  of 
our  position,  that  the  peritoneal  inflammation  of  child-bed  wo- 
men, and  "the  low  fever  of  child-bed,"  are  one  and  the  same 
disease. 

For,  had  Dr.  Clarke  told  us  he  had  never  found  "  the  parts 
under  the  crust  or  coat  inflamed,"  it  would  not  have  permitted 
us  to  doubt  for  a  moment  the  identity  of  the  affections,  for  the 
reasons  stated  above.  For  this,  and  every  other  species  of  in- 
flammation may  throw  out  even  large  quantities  of  fluid  under 
certain  stages  of  its  continuance ;  but  when  it  does,  the  inflam- 
mation which  gave  rise  to  the  effusion  becomes  relieved,  either 
altogether,  or  in  part,  as  this  effusion  may  be  more  or  less  exten- 
sive, or  as  the  inflammation  may  have  been  more  or  less  exalted. 

"We  have  noticed  above  the  prevalence  of  puerperal  fever,  as  an  epidemic  in 
Northumberland  (in  this  state,)  and  its  neighbourhood;  situations  very  remote 
from  either  hospitals,  or  towns  of  any  considerable  size. 


368  PUERPERAL    FEVER. 

These  effects  are  familiar  to  every  body ;  for  they  present  them- 
selves to  us  almost  daily,  in  the  consequences  of  burns,  scalds, 
and  blisters. 

II.  We  are  led  to  suppose,  that  Dr.  Clarke  infers  a  difference 
in  the  two  diseases  under  consideration,  from  the  immense  quan- 
tity of  fluid  found  in  the  cavities  of  the  abdomen  of  those  who 
have  died  of  the  "low  fever  of  child-bed,"  and  which  bears  no 
proportion  to  the  "  degree  of  inflammation,  or  the  extent  of  in- 
flamed surface,"  and  the  extent  of  the  inflammation  and  the 
smaller  quantity  of  fluid  found  in  the  abdomen  of  those  who  died 
from  peritoneal  inflammation. 

Now,  in  our  estimation,  this  should  show  the  most  entire  iden- 
tity of  the  two  diseases,  instead  of  proving  a  difference.  For,  in 
the  one  instance,  there  was  a  stronger  disposition  to  effusion 
arising  from  the  peculiarity  of  the  inflammation,  but  which  pe- 
culiarity was  the  result  of  an  epidemic  influence;  and  the  reduc- 
tion of  this  inflammation  kept  pace  with  the  profuseness  of  the 
effusion.  In  the  other  instance,  the  same  circumstances  obtained 
precisely;  that  is,  the  abatement  of  inflammation  was  in  exact 
proportion  to  the  effusion;  hence,  more  inflammation  and  less 
effusion  was  discoverable  in  one  case  than  in  the  other ;  because, 
in  the  one  case  the  extent  of  inflammation  was  less,  or  there  was 
less  disposition  to  effusion. 

Physicians  and  surgeons  have  ever  entertained  their  own  no- 
tions as  regards  the  type  of  every  epidemic  with  which  we  are 
acquainted:  and  their  mode  of  treatment  must,  consequently,  be 
predicated  upon  such  opinions.  Thus,  in  the  yellow  fever  of 
1793,  some  physicians  looked  upon  it  as  a  "putrid  fever,"  and, 
accordingly,  treated  it  with  bark,  wine,  and  other  stimuli ;  while 
others  considered  it  slightly  inflammatory  in  the  commencement, 
but  typhoid  in  its  progress:  these  bled  a  few  ounces  on  the  first 
or  second  day;  purged  gently;  and  then  used  bark,  wine,  carbo- 
nate of  ammonia,  &c.  Others  looked  upon  it  as  a  fever  of  high 
inflammatory  character;  to  subdue  which,  extensive,  and  some- 
times repeated  bleedings,  profuse  purging,  and  a  strict  antiphlo- 
gistic plan  was  pursued.  Now,  it  cannot  be  supposed,  that  all 
these  opinions  were  right;  yet  each  attempted  to  support  the  pro- 
priety of  his  practice,  by  detailing  such  phenomena  and  effects 
as  were  most  likely  to  answer  this  end.  Hence  resort  was  had 
to  dissections,  and  each  found  a  justification  of  his  practice,  as  he 
supposed,  in  the  post  mortem  appearances.  But,  after  awhile,  it 
was  discovered,  that  the  first  plan  was  entirely  without  success ; 
that  the  second  had  some,  but  it  was  very  limited ;  while  the  third 
was  attended  by  a  fair  proportion  of  recoveries. 

Just  so  has  it  been  with  puerperal  fever;  for  the  rapidity  of  its 
march,  and  the  strong  tendency  of  the  body  after  death  to  putre- 
faction, led  to  the  belief  that  it  could  be  no  other  than  a  putrid,  or 


PUERPERAL  FEVER. 

typhoid  fever;  and  the  want  of  success  in  curing  it,  by  the  reme- 
dies proper  for  such  diseases,  was  not  attributed  to  the  improper 
nature  of  the  means  employed,  but  to  the  indomitable  nature  of 
the  disease  itself.  Therefore,  wrong  pathological  views  led  them 
either  to  a  feeble  or  inefficient  practice,  or  to  one  decidedly 
wrong.1 

Dr.  Clarke,  intent  upon  advancing  the  interests  of  his  profes- 
sion, and  indefatigable  in  the  duties  which  a  large  share  of  busi- 
ness constantly  imposed  upon  him,  attempted  to  remove  the  ob- 
scurities which  seemed  always  to  await  this  formidable  disease, 
by  making  the  various  affections  of  the  puerperal  state  conform 
to  a  certain  classification.  With  this  in  view,  he  divides  the  de- 
rangements of  the  uterine  system,2  and  the  peritoneum,  into  the 
following  classes : — 

1st.  Into  the  inflammation  of  the  uterus  and  ovaria. 
2d.  The  inflammation  of  the  peritoneum. 
3d.  Cases  of  inflammation  of  the  uterus,  ovaria,  and  Fallo- 
pian tubes,  or  of  the  peritoneum,  connected  with  an 
inflammatory  state  of  the  system. 
4th.  The  low  fever  of  child-bed,  &c.3 

The  doctor  was  solicitous  that  these  several  affections  should 
not  be  confounded;  to  prevent  which,  he  admonishes  the  inexpe- 
rienced practitioner  in  the  following  words:  "Before  I  close  this 
part  of  my  subject,  I  must  beg  leave  to  caution  those  of  my 
readers,  whose  experience  may  have  been  short,  to  be  very  care- 
ful in  distinguishing  these  diseases  from  cases  of  fever  consequent 
to  labour,  occurring  in  debilitated  constitutions,  in  large  towns, 

1  It  is  but  just,  however,  to  state,  that  the  researches  of  Tonnelle  and  Duplay 
have  led  to  the  conclusion,  that  puerperal  fever  does  not  always  consist  of  a  purely 
inflammatory  action— but  on  the  contrary,  that  in  "la  Maternitfe,"  this  condition 
was  comparatively  rare;  hence,  they  have  divided  it  into  the  inflammatory,  ty- 
phoid, and  the  ataxic  varieties.  The  typhoid  was  by  far  the  most  frequent,  and 
the  ataxic  the  most  rare,  while  the  purely  inflammatory  occurred  but  thirty-nine 
times  in  two  hundred  and  twenty-two  of  the  fatal  cases  examined  by  them.  This, 
however,  must  only  be  received  as  the  reports  of  the  type  of  the  disease  as  it  ap- 
peared in  that  hospital ;  and  though  no  modifying  circumstance  could  be  discovered 
in  that  institution,  yet  it  is  every  way  certain  there  must  have  been  one,  and  that 
this  account  will  not  serve  as  an  infallible  guide  for  the  treatment  of  this  disease 
in  this  country.  This  peculiarity  in  the  influence  of  an  hospital  atmosphere  has 
been  lately  proved  in  the  Pennsylvania  Hospital  of  this  city;  for  the  cases  of  puer- 
peral fever  which  presented  themselves  were  fatal  in  an  unprecedented  degree,  yet 
this  disease  was  confined  to  this  place,  as  it  did  not  occur  in  private  practice,  at 
least  we  did  not  meet  with  a  single  case.  Yet  even  in  the  most  frequent  form  of 
this  disease,  (the  typhoid,)  in  the  Paris  Hospital,  it  was  acknowledged  that  the 
typhoid  symptoms  were  preceded  by  an  inflammatory  stage,  and  this  is  all  that 
we  absolutely  contend  for. 

a  By  the  uterine  system,  we  would  wish  to  be  understood  only  such  portion  of 
it,  as  is  within  the  abdominal  cavity,  or  such  parts  as  have  a  peritoneal  covering. 

'  Modern  pathologists  pay  no  attention  to  which  part  the  inflammation  makes 
its  appearance — it  is  very  essential  to  the  production  of  puerperal  fever  that  any 
portion  of  the  serous  or  peritoneal  coat  be  the  seat. 

24 


370  PUERPERAL   FEVER. 

and  in  hospitals  more  particularly,  where  there  is  any  disposition 
to  epidemic  complaints,  which  have  a  low  tendency,"  p.  92. 

But,  notwithstanding  the  apparent  propriety  of  these  divisions, 
and  the  earnestness  of  his  cautions,  he  has  not,  in  the  smallest 
degree,  facilitated  "  those  whose  experience  may  have  heen  short," 
(and  we  may  add,  those  whose  experience  has  been  long,)  to  dis- 
tinguish, with  any  profitable  accuracy,  the  different  conditions  he 
has  described.  Nor  is  this  to  be  wondered  at ;  as  he  has,  in  the 
very  threshold  of  his  inquiry,  created  confusion  by  neglecting 
a  most  important  part  of  his  subject;  namely,  not  informing  us, 
in  what,  or  from  what,  condition  of  the  system  this  fever  pro- 
ceeds. 

For  it  will  be  perceived,  that  notwithstanding  his  attempts  at 
distinctions  in  this  division  of  the  seats  of  this  disease,  they  are 
truly  without  differences ;  as  they  are  at  last  all  resolvable,  and 
this,  strictly  speaking,  into  peritoneal  inflammation.  In  his  first 
division,  he  declares  the  uterus  and  ovaria  to  be  involved:  now, 
it  is  obvious  in  this  case,  that  the  ovaria  cannot  well  be  inflamed 
to  the  exclusion  (for  we  will  omit  the  condition  of  the  abdominal 
portion  of  the  uterus)  of  their  peritoneal  covering;  consequently 
this  first  division  must  mean  "puerperal  fever,"  if  this  fever  con- 
sists of  an  inflammation  of  the  peritoneum,  as  we  have  already 
insisted  on. 

His  second  division,  a  fortiori,  must  be  considered  as  puerperal 
fever;  since  its  distinctive  mark  consists  in  an  "inflammation  of 
the  peritoneum."  We  have  already  noticed,  p.  354,  Dr.  Clarke's 
attempt  to  institute  a  distinction  between  this  condition  of  the 
abdomen,  and  the  "low  fever  of  child-bed; "  we  shall,  therefore, 
not  repeat  what  we  have  said  there. 

His  third  division  is  still  more  exceptionable;  because  it  insi- 
nuates that  an  inflammation  of  that  portion  of  the  peritoneum 
which  covers  the  uterus,  ovaria,  and  Fallopian  tubes,  is  different 
from  an  inflammation  of  other  portions  of  this  membrane;  and 
he  considers  it  necessary  that  an  inflammation  of  these  parts 
should  be  distinguished  from  inflammation  of  other  portions  of  the 
peritoneum,  which  we  hold  to  be  impossible.  And  were  it  possi- 
ble, no  kind  of  practical  good  could  result  from  the  discrimination. 
His  fourth  appears  to  be  in  opposition  to  his  own  facts,  or  even 
reasonings.  In  this,  he  attempts  to  prove  that  "  the  low  fever  of 
child-bed"  is  not  a  peritoneal  inflammation.  We  have  already 
noticed  this  effort,  p.  354. 

From  what  we  have  said,  we  think  we  may  safely  draw  the 
following  conclusions :  first,  that  the  distinctions  attempted  to  be 
made,  of  an  essential  difference  in  the  nature  of  the  disease  from 
the  location  of  the  inflammation  within  the  abdomen,  is  without 
foundation.  For  it  does  not  appear,  from  all  we  learn  from 
others,  that  the  inflammation  of  puerperal  fever  is  ever  confined. 


PUERPERAL    FEVER.  371 

strictly,  to  any  one  portion  of  the  peritoneum;  and  from  Dr. 
Clarke's  own  acknowledgment,  "The  surface  of  the  stomach, 
liver,  spleen,  omentum,  great  and  small  intestines,  uterus,  the  in- 
ternal lining  of  the  muscles  of  the  abdomen,  will,  in  their  turn, 
or  altogether,  be  found  to  partake  of  the  disease ;  and,  as  far  as 
my  experience  leads  me  to  judge,  no  part  more  than  another" 
See  page  355. 

We  must  look  upon  the  peritoneum  as  a  unit;  and  that  when 
inflamed  in  any  one  part,  the  same  general  symptoms  will  arise ; 
and  that  the  whole  of  it  is  now  liable,  from  this  cause,  to  be  in- 
rolved  in  the  same  condition  as  that  part:  hence,  if  the  inflam- 
mation commence  at  any  given  point,  it  may  travel  over  the 
whole,  or  a  great  portion  of  its  surface,  or  it  may  be  confined  to 
the  original  focus. 

A  want  of  attention  to  this  circumstance  has  led  all  the  wri- 
ters,1 so  far  as  we  recollect,  into  the  error  of  considering  the  in- 
flammation of  the  peritoneal  covering  of  the  uterus  as  a  distinct 
disease  from  puerperal  fever,  by  calling  it  an  inflammation  of 
the  uterus.  In  this,  there  is  a  great  want  of  precision ;  for  the 
inflammation  of  the  uterus,  properly  so  called,  is  a  very  distinct 
disease  from  peritoneal  inflammation.  (See  Chap,  on  Inflam- 
mation of  the  Uterus.) 

Dr.  Denman  very  properly  observes,  "  There  is  undoubtedly 
much  difliculty  in  forming  a  just  idea  of  a  very  complicated  dis- 
ease ;  and  in  proportion  to  the  difliculty,  every  attempt  to  make 
accurate  distinctions  is  deserving  of  commendation."  To  this 
we  most  willingly  assent.  But  he  adds  immediately  after,  "But, 
however  symptoms  may  vary  from  affections  of  particular  parts, 
or  in  particular  constitutions,  there  is  but  one  essential  nature  of 
the  disease ;  and  if  we  have  a  true  notion  of  this,  we  have  less 
reason  to  be  solicitous  about  the  cause,  or  the  determination  of 
the  part  originally  or  principally  affected.  For  a  similar  treat- 
ment may  be  enjoined,  with  equal  propriety,  for  an  inflammation 
of  the  uterus,  omentum,  peritoneum,  or  intestines,  or  perhaps 
any  of  the  contents  of  the  abdomen ;  whether  the  disease  remain 
local,  or  a  fever  be  produced  by  its  influence  being  extended 
to  the  constitution  in  general." — Introd.  to  Mid.,  Francis's  ed. 
p.  565. 

Yet  is  Dr.  Denman  himself  betrayed  into  a  want  of  precision 
in  the  very  next  sentence ;  for  he  says>  that  "  the  inflammation  of 
the  uterus  is  far  less  dangerous  than  an  equal  degree  of  inflam- 
mation of  any  of  the  viscera  of  the  abdomen,  especially  in  the 

•••:.ii  "'mil  ?<•!» 

1  Dr.  Armstrong  might  have  been  looked  upon  as  an  exception,  as  he  mentions 
"  simple  hysteritis ;"  did  he  not  immediately  after  appear  to  lose  sight  of  the  dis- 
tinction, by  following  Dr.  Denman  and  Dr.  Baillie;  especially  the  latter,  who 
speaks  of  "  inflammation  of  the  uterus  and  its  appendages,"  under  the  head  of  in- 
flammation of  the  uterus.— Morbid  Anatomy,  p.  362.  See  also  text  below. 


372  PUERPERAL    FEVER. 

state  of  child-bed ;  because  the  uterus  readily  admits  of  a  return 
of  the  lochial  discharge,  which  always  affords  relief,  and  some- 
times cures  the  disease." 

Here  we  are  at  a  loss  to  understand,  whether  by  an  inflamma- 
tion of  the  uterus,  it  is  intended  to  include  its  coverings,  or  to 
strictly  confine  the  inflammation  to  the  substance  of  the  uterus 
without  its  covering  being  involved.  We  are,  however,  inclined 
to  believe  he  meant  the  whole  mass  of  this  organ,  from  what  im- 
mediately follows :  "  Because  the  uterus  readily  admits  of  a  return 
of  the  lochial  discharge,  which  always  affords  relief,  and  some- 
times cures  the  disease." — Ib.  We  shall  merely  remark  upon 
this  last  passage,  en  passant,  that  Dr.  Denman  has  evidently  mis- 
taken an  effect  for  a  cause.  For,  in  inflammation  of  the  uterus, 
the  lochia  do  not  return  until  this  condition  is  relieved ;  and  if 
the  inflammation  be  relieved  by  any  cause,  so  as  to  permit  the 
lochial  discharges  to  return,  it  is  evident  that  the  reduction  of 
the  inflammation  is  the  cause  of  the  return  of  the  lochia,  and 
that  the  disease  is  subsiding,  but  not  a  proof  that  the  lochial 
discharge  is  the  cause  of  the  diminution  of  the  inflammation ; 
for  this  discharge  would  not  take  place  unless  preceded  by  this 
reduction  of  inflammation,  though  it  may  ultimately  contribute 
to  this  end  by  its  continuance. 

Dr.  Armstrong,  however,  quotes  the  above  passages  differently : 
he  makes  Dr.  Denman  to  say,  "When  simple  liysteritis  takes 
place,"  &c.  But  this  reading  of  Dr.  Armstrong  is  entirely  gra- 
tuitous ;  for  there  is  no  mention  made  of  the  simple  inflammation 
of  the  uterus  by  Dr.  Denman ;  and  this  is  the  very  fault  we  com- 
plain of.  Nor  does  Dr.  Baillie  discriminate  any  better ;  for,  in 
speaking  of  the  inflammation  of  the  uterus,  he  says,  "the  inflam- 
mation is  sometimes  confined  to  the  uterus  itself,  (evidently 
meaning  it  as  a  whole,)  or  its  appendages;"  and  that  he  means 
to  distinguish  this  organ  from  its  neighbouring  parts,  is  indispu- 
table; for  he  adds,  "But  the  peritoneum  in  the  neighbourhood  is 
most  commonly  affected,  and  frequently  over  its  whole  extent." 
That  is,  (as  we  understand  it,)  when,  the  uterus  is  inflamed,  the 
neighbouring  peritoneum  is  also  most  commonly  inflamed;  con- 
sequently, if  this  be  so,  it  is,  to  all  intents  and  purposes,  puerperal 
fever,  and  not  a  simple  inflammation  of  the  uterus. 

It  would,  in  our  opinion,  be  always  best,  when  post  mortem 
examinations  are  related,  in  which  the  fundus  of  the  uterus  is 
found  inflamed,  to  say  that  the  peritoneal  covering  of  the  uterus 
was  found  "inflamed;"  instead  of  saying,  "The  uterus  was  in- 
flamed ;"  for  this  may  not  have  been  the  case,  strictly  speaking, 
— See  Chapter  on  Inflammation  of  the  Uterus. 

And,  secondly,  we  may  conclude  that  Dr.  Clarke  has  failed  to 
establish  any  other  difference  between  "peritoneal  inflammation," 
and  the  cause  of  the  "  low  fever  of  child-bed,"  than  that  which  is 


PUERPERAL    FEVER.  373 

frequently  observed  to  exist  between  "sporadic  and  epidemic 
puerperal  fever."  We  have  already  said  enough  respecting  epi- 
demic influence,  to  convince  any  one  of  the  extent  of  its  agency 
upon  this,  and  many  other  diseases. 


Of  the  Period  of  Attack,  and  Symptoms. 

In  comparing  the  histories  of  the  symptoms  of  this  disease,  as 
detailed  by  a  number  of  authors,  with  what  we  ourselves  have 
seen,  we  think,  taking  the  whole  of  the  description  together,  that 
drawn  up  by  Dr.  Denman  appears  to  be  the  most  faithful.  It 
seems  to  be  the  result  of  very  extensive  observation,  and  com- 
bines, within  a  very  moderate  space,  all  that  is  essential  to  dis- 
criminate the  disease  in  its  commencement;  and  to  recognise  it 
easily  in  its  advancement  and  terminations.  For  this  reason,  we 
will  detail  the  symptoms  and  characters  of  the  disease  in  his  own 
words.  We  are  the  more  disposed  to  do  this,  because  our  expe- 
rience, though  sufficient  to  convince  us  of  the  fidelity  of  his  ac- 
count of  the  disease,  has  not  been  so  ample  as  to  enable  us  to 
make  any  important  divisions. 

"  The  time  when  women  are  chiefly  subject  to  this  fever  is 
uncertain.  There  are  not  wanting  instances  in  which  it  has  been 
evidently  forming  before  delivery,  or  during  labour,  or  at  any 
intermediate  period  for  several  weeks  afterwards ;  and  the  sooner 
from  the  time  of  delivery  the  patient  is  attacked,  if  in  an  equal 
degree,  far  greater  is  the  attendant  danger.  But  the  most  fre- 
quent time  of  its  appearing  is  on  the  third  or  fourth  day  after 
delivery,1  when  the  patient  is  seized  with  a  shivering  fit,  from 
the  violence  and  duration  of  which,  we  may  generally  estimate 
the  danger  of  the  succeeding  disease.2  In  some  cases,  however, 
there  has  been  no  cold  or  shivering  fit,  or  none  which  was  ob- 
servable; and  in  others,  the  shivering  fit,  in  the  state  of  child-bed, 
has  not  been  followed  by  those  symptoms  which  were  to  be  ap- 
prehended.3 

1  Authors  differ  a  little  as  to  the  period  at  which  the  disease  may  attack  after 
delivery.  Hey  says,  about  forty-eight  hours;  Armstrong,  from  twenty-four  to 
thirty  hours;  Clarke,  on  the  second,  third,  and  even  the  eighth  day;  Leake,  on 
the  evening  of  the  second  day,  or  the  morning  of  the  third,  &c. 

*  This  disease  is  not  always  announced  by  rigour  or  chill.  Hull,  Hey,  Arm- 
strong, Leake,  &c.,  agree  it  is  generally  preceded  by  shiverings;  but  that  they 
are  by  no  means  essential  to  its  formation.  Clarke  says  it  rarely  happened.  Mr. 
Hey  says  that  "  some  of  the  worst  cases  were  unattended  by  rigor;  and  in  others, 
equally  severe,  there  was  no  more  than  a  slight  chilliness,"  p.  28.  And  Dr.  Mar- 
shall Hall  says  that  in  puerperal  diseases,  "pure  inflammation  is  less  marked  by 
rigour,  heat,  and  other  obvious  symptoms,  than  the  effects  of  intestinal  irritation." 

3  Dr.  Denman  has  not  discriminated  with  his  usual  accuracy  in  this  instance :  a 
mere  shivering,or  rather  trembling  after  delivery,  is  no  very  uncommon  occurrence; 
but  this  agitation  is  not  accompanied  by  the  sensation  of  cold,  though  it  goes  under 


PUERPERAL    FEVER. 

"  Before  the  shivering  fit,  the  patients  have  been  much  debili- 
tated,1 and  have  complained  of  wandering  pains  in  the  abdomen, 
•which  very  soon  became  fixed  in  the  hypogastric  region,  where 
a  swelling  or  fulness,  with  exquisite  tenderness,  soon  ensued.2 
As  the  disease  advances,  the  whole  abdomen  becomes  affected 
and  tumefied,  sometimes  nearly  to  its  size  before  delivery,  the 
woman  herself  being  sensible  of,  and  describing  its  progress. 
She  also  feels  great  pain  in  the  back,  hips,  and  sometimes  in  one 
or  both  legs,  and  other  parts  affected  in  uterine  complaints. 

"  She  scarcely  can  lie  in  any  other  position  than  on  her  back, 
or  on  one  side  with  her  body  incurvated ;  and  if  the  disease  be 
confined  to  the  uterus,  the  seat  of  the  pain  seems  to  be  changed 
when  she  alters  her  position.3 

"  There  is  either  a  vomiting  of  a  green  or  yellow  bitter  mat- 
ter, or  a  nausea  or  loathing  of  the  stomach,  with  an  offensive 
taste  in  the  mouth.4  An  instantaneous  change  both  in  the  quan- 
tity and  appearance  of  the  lochia  takes  place;  and  sometimes, 
though  rarely,  they  are  wholly  suppressed.5  The  milk,  if  se- 

i'it  f  1  '••  •*''•  •'''!   'tijf'j  ''*•  *•  TV     A  <•  "'_ii/ »>',*'  "  c\'/i ' 
ill  or  shivering,  by  those  who  are  unacquainted  with  the  pheno- 
mena of  fever.     It  is,  therefore,  represented  to  the  physician  as  such;  but  he  does 
not  find  it  to  be  followed  by  reaction;  hence  it  is  said,  the  chill  was  not  followed 
by  fever. 

1  We  presume  Dr.  Denman  means,  by  their  being  much  debilitated,  a  sudden 
loss  of  strength,  which  is  by  no  means  uncommon,  previously  to  the  attack  of  se- 
vere and  dangerous  fevers;  this  is  remarkably  the  case  in  those  seized  by  yellow 
fever.  It  cannot  mean,  they  "  were  much  debilitated"  by  the  fatigue  of  labour; 
for  he  and  many  others  declare  that  the  contingencies  of  labour  do  not  appear  to 
have  any  agency  in  the  production  of  the  disease. 

*  We  would  wish  to  direct  the  attention  of  the  reader  to  this  circumstance;  it 
is  one  in  which  all  appear  to  agree;  and  which  seems  to  settle  the  point  agitated 
by  Dr.  Clarke  and  others,  namely,  whether  the  fever  was  the  consequence  of  a 
local  inflammation  of  the  peritoneum;  or  whether  the  inflammation  was  the  COM- 
sequence  of  the  fever;  for  it  is  here  declared,  pain,  &c.,  existed  before  the  rigour. 

3  Dr.  Denman  unquestionably  means,  by  the  "  uterus,"  the  peritoneal  covering 
of  this  organ  and  its  appendages.     But  this  mode  of  expressing  the  condition  of 
this  part  must  unavoidably  create  confusion,  as  we  have  taken  occasion  to  remark 
in  another  place,  as  this  viscus  is  liable  to  become  inflamed,  independently  of  its 
peritoneal  coat,  and  which  is  a  very  different  and  much  less  dangerous  disease. 
Mr.  Hey  is  also  faulty  in  this  respect,  for  he  says, "  But  all  the  varieties,  so  far  as 
I  can  judge  from  ray  experience  and  reading,  may  be  reduced  to  two  denomina- 
tions, the  sporadic  and  the  epidemic  puerperal  fevers,  in  which  I  include  inflamma- 
tion of  the  uterus  and  peritoneum*     Dr.  Armstrong  runs  into  the  same  error. 

4  Dr.  Clarke  supposes  that  many  of  the  local  symptoms  arise  from  an  inflamma- 
tion of  that  portion  of  the  peritoneum  which  may  invest  the  particular  organ  or 
part, "  such  as  constant  sickness  and  vomiting  of  bilious  matter,  when  the  stomach 
is  attacked,"  p.  84.     This  we  believe  to  be  a  sound  explanation  of  the  vomiting 
when  it  occurs  in  puerperal  fever,  unless  it  be  in  such  instances,  in  which  this 
action  proceeds  from  offensive  matters  in  the  stomach.     But  vomiting  is  by  no 
means  a  constant  symptom  in  the  early  stage  of  peritonitis;  indeed  we  would  say 
that  it  is  rare,  if  our  limited  experience  will  authorize  such  a  declaration;  and 
when  it  does  occur,  it  is  almost  always  in  the  second:  it  is  then  obstinate,  and 
may  be  regarded  as  a  most  unfavourable  symptom;  and  this  for  the  reason  as- 
signed by  Dr.  Clarke. 

*  All  the  writers  on  the  subject  of  puerperal  fever  agree  in  the  uniformity  of 


PUERPERAL    FEVER. 

creted,  recedes,  or  is  diminished,  and  the  taste,  with  the  appear- 
ance, is  much  altered.1 

"•  The  urine  is  voided  often,  with  pain,  and  in  small  quantities, 
and  is  remarkably  turbid.  A  tenesmus  or  frequent  stools  come 
on,  and,  from  the  general  disturbance,  it  is  often  manifest  that 
all  the  contents  of  the  pelvis  are  at  once  affected  by  the  disease. 
"  The  tongue  becomes  dry,  though  sometimes  it  remains  moist, 
and  is  covered  with  a  thick  brown  fur;  but,  as  the  disease  ad- 
vances, its  appearance  varies,  and  in  some  dangerous  cases  it 
has  been  little  changed.2  The  patient  immediately  entertains 
the  strongest  apprehensions  of  her  danger,  and  usually  labours 
under  vast  anxiety,  her  countenance  bearing  indubitable  marks 
of  great  suffering  both  in  body  and  mind. 

"The  progress  of  this  disease  is  sometimes  extremely  rapid, 
and  especially  in  unfavourable  seasons,  and  in  hot  climates.     In- 
stances have  occurred  in  which  women  have  died  within  twenty- 
four  hours  after  the  first  attack ;  and  I  have  seen  a  few  who  never 
frew  warm  after  the  rigour,  which  then  resembled  a  convulsion, 
n  some,  death  has  followed  quite  unexpectedly,  either  from  in- 
attention, or  from  the  scarcely  perceptible  but  insidious  pro- 
gress of  the  disease,  the  indications  not  having  been  at  all  pro- 
portionate to  the  danger. 

these  symptoms.  All  declare  the  change  which  takes  place  in  the  lochia  imme- 
diately after  the  disease  is  formed,  if  we  except  Leake,  who  says  it  was  not  affected 
either  in  quality  or  quantity ;  a  presumption,  he  says,  that  the  uterus  was  not 
affected;  and  all  agree  that  it  constitutes  one  of  the  most  decided  symptoms  in  this 
complaint.  By  what  agency  is  this  change  effected  ?  Does  it  prove  that  the 
uterus,  both  in  its  substance  and  covering,  is  always  implicated  in  this  disease  ? 
or  does  it  show  there  is  a  prevailing  sympathy  between  the  inflamed  peritoneum 
and  the  surface  which  yields  the  lochia  t  Is  the  first  rendered  probable  by  the 
lochia  being  deranged  when  the  substance  of  the  uterus  is  known  to  be  affected, 
in  the  same  manner  as  when  the  peritoneum  is  inflamed  ?  Mr.  Hey,  however, 
says  it  is  sometimes  not  affected,  p.  23.  Are  we  to  pronounce  in  such  cases  that 
the  uterus  is  uninjured?  or,  if  not  uninjured,  what  part  has  escaped. 

'The  want  of  secretion  of  the  milk,  if  the  disease  occur  before  the  breasts  are 
prepared  for  it;  and  its  cessation,  if  it  has  been  secreted  immediately  after  the 
formation  of  puerperal  fever,  is  one  of  the  most  uniform,  as  well  as  one  of  the  most 
remarkable  symptoms  attending  this  disease;  and  it  would  seem  to  prove  one  of 
two  things :  first,  that  the  inflamed  peritoneum  has  a  control  over  this  secretion,  a 
sympathy  only  manifest  at  this  particular  time;  or  secondly,  that  that  condition 
of  the  uterus  by  which  the  mamma;  are  influenced  to  the  secretion  of  milk,  is 
changed,  by  the  presence  of  inflammation,  either  in  its  covering,  or  substance,  or 
both:  but  most  probably  from  its  peritoneal  covering  being  affected,  as  in  simple 
hysteritis,  the  breasts  are  never  so  much  affected,  and  sometimes  not  at  all. 

*  Mr.  Hey,  in  speaking  of  the  Leeds  puerperal  fever,  says,  "  The  tongue  was 
never  incrusted  with  the  brown  dry  fur  of  typhus,  except  the  disease  was  of  long 
continuance,  or  had  been  improperly  treated.  It  was  generally  moist  and  soft, 
and  though  it  was  not  unfrequently  covered  with  a  thick  white  or  brownish  fur, 
yet  it  was  often  but  little  altered  from  its  natural  appearance,  to  the  last,  even  in 
bad  cases,"  p.  32.  Dr.  Armstrong  says, "  The  tongue  was  much  paler  than  usual, 
and  appeared  as  if  it  had  been  recently  rubbed  or  dusted  with  a  very  fine  whitish 
powder :  in  some  instances  the  tongue  was  tolerably  clean  and  moist  about  the 
edges,"  p.  2. 


376  PUERPERAL    FEVER. 

"In  other  cases  the  shivering  fit  is  succeeded  by  heat,  thirst, 
and  other  symptoms,  according  to  the  course  observed  in  other 
fevers ;  but  the  pain  which  originated  in  the  abdomen,  joined  with 
these,  is  to  be  esteemed  the  pathognomonic  or  chief  sign  of  the 
disease.  It  seems  necessary  to  enumerate  all  the  symptoms,  which 
commonly,  though  not  exclusively,  attend  this  fever,  and  not  in 
any  individual  patient;  yet  cases  will  occur  in  practice,  in  which 
there  will  be  much  variation,  depending  on  the  degree  of  disease, 
the  parts  affected,  the  constitution  of  the  patient,  and  the  period 
after  delivery  when  the  fever  makes  its  appearance. 

c*  The  pulse  has  almost  invariably,  in  this  disease,  an  unusual 
quickness  from  the  beginning.1  It  has  often  that  strength  and 
vibration  observed  in  the  disorders  of  the  most  inflammatory 
kind,  in  robust  constitutions;  and  yet  is  sometimes  exceedingly 
feeble  and  quick,  beyond  what  might  be  expected  from  the  con- 
curring circumstances.  The  latter  is  to  be  reckoned  among  the 
most  dangerous  signs,  proving,  perhaps,  increased  irritability, 
with  great  violence  of  disease,  and  that  the  powers  of  the  system 
are  unable  to  struggle  with  it,  or  scarcely  to  bear  the  operation 
of  the  medicines  which  might  be  necessary  for  its  relief. 

"  There  is  much  variation  in  the  subsequent  stages,  but  there 
is  scarcely  a  worse  omen  than  a  very  weak  and  accelerated 
pulse,  even  though  the  other  symptoms  may  seem  to  be  abated. 
But  the  mere^ quickness  of  the  pulse,  if  not  attended  with  other 
perilous  signs  of  inflammation  or  fever,  is  not  to  be  considered 

1  The  frequency  of  the  pulse  in  peritoneal  inflammation  has  been  so  invariable, 
agreeably  to  our  observations,  that  we  regard  it  as  pathognomonic.  We  were, 
therefore,  not  a  little  surprised  to  find  this  condition  of  the  artery  denied  by  Dr. 
Marshall  Hall,  in  his  Essays  on  some  of  the  more  important  Diseases  of  Females, 
p.  177.  He  says,  "  Frequency  of  pulse  is  not  a  less  uncertain  indication  of  inflam- 
mation (peritoneal.)  I  am  enabled  to  say,  from  careful  observation,  that  the 
pulse  is  but  little  accelerated  in  many  cases  of  puerperal  inflammation  within  the 
abdomen,  whilst  it  is  excessively,  and  even  alarmingly,  frequent  in  some  cases  in 
which  inflammation  does  not  exist."  We  cannot  but  suspect  that  the  doctor  la- 
bours under  a  great  error  in  this  statement;  at  least,  in  the  first  part  of  it — we 
think  he  has  probably  confounded  pure  hysteritis  with  peritoneal  inflammation. 
See  page  365.  The  latter  declaration  we  fully  agree  to;  but  it  adds  no  support 
to  the  former  part  of  his  observations.  We  are  the  more  inclined  to  suspect  a 
want  of  accuracy  in  Dr.  Hall's  observation,  from  the  loose  manner  in  which  he 
has  conveyed  his  notions  of  the  seats  of  the  inflammation  constituting  the  disease 
in  question.  For  he  says, "  Considering  the  important  and  sudden  changes  which 
take  place  in  the  condition  of  the  uterus,  in  parturition,  we  cannot  be  surprised 
that  its  appendages,  the  adjacent  viscera,  and  the  peritoneum  at  large,  should,  not 
unfrequently,  participate  in  this  morbid  condition,"  p.  156.  Now,  from  this  quo- 
tation, it  would  appear  evident  that  the  appendages  of  the  uterus,  and  the  abdo- 
minal viscera  may  be  inflamed  in  puerperal  women,  independently  of  the  perito- 
neum, a  circumstance  that  has  not,  we  believe,  been  verified  by  late  pathological 
research.  The  uterus  itself  may,  beyond  all  doubt;  but  the  abdominal  viscera 
do  not  appear  to  follow  this  rule.  Dr.  H.  seems  to  forget  that  Bichat  has  taught 
us  that  investing  membranes  maybe  inflamed  without  implicating  the  other  tissues 
of  the  organs  over  which  they  spread;  and,  consequently,  that  an  inflammation 
of  the  peritoneum  covering  the  liver,  is  not  an  inflammation  of  this  organ,  &c. 


PUERPERAL   FEVER.  377 

as  indicating  danger ;  experience  having  shown  that  very  irritable 
patients  have  sometimes  an  unusually  quick  pulse,  unaccompanied 
with  any  other  alarming  symptom. 

"  The  signs  of  inflammation,  joined  with  those  of  extreme  irri- 
tability, continue  for  a  few  days,  when  those  of  putridity  appear ; 
sooner,  perhaps,  in  this,  than  in  most  other  diseases,  which  are 
originally  of  the  truly  inflammatory  kind.1  The  teeth  very  early 
collect  a  brown  adhesive  sordes,  and  all  kinds  of  food  and  drink 
are  nauseated,  except  such  as  are  agreeable  from  their  coldness 
or  sharpness. 

"A  singultus  attends;  every  return  of  which  affects  the  ab- 
domen in  the  most  painful  manner.  Petechise  or  vibices  are  often 
found  in  unwholesome  situations,  and  in  some  constitutions  of 
the  air,  at  a  very  early  period  of  the  disease,  and  there  are 
frequently  miliary  eruptions ;  but  the  latter  seem  to  be  rather  a 
consequence  of  the  method  of  treatment  than  of  the  disease,  for 
they  do  not  afford  that  relief  which  sometimes  follows  their  ap- 
pearance in  true  eruptive  fevers. 

"  The  bowels  are  in  general  very  much  disturbed,  and  in  some 
cases  a  looseness  takes  place  immediately  upon  the  accession ;  in 
others,  in  three  or  four  days  after,  or  not  till  the  last  stage  of  the 
disease ;  but  it  very  seldom  fails  to  attend,  nor  can  it  be  removed 
without  the  greatest  difficulty,  as  well  as  danger,  before  the  dis- 
ease is  terminated.  The  stools,  before  the  close,  often  come  away 
involuntarily,  being  always  preceded  by  an  increase  of  pain ;  and 
every  evacuation  gives  a  momentary  relief.  They  are  uncom- 
monly fetid,  of  a  green  or  dark  brown  colour,  and  working  like 
yeast.  It  is  also  remarkable  that,  after  the  long  continuation  of 
the  looseness,  when  the  patient  has  taken  little  or  no  solid  nou- 

1  This  circumstance  is  familiar  to  all  who  have  witnessed  the  most  inflammatory 
of  all  fevers,  namely  the  yellow  fever.  This  disease  runs  its  course  sometimes 
with  such  rapidity  that  the  stages,  from  the  highest  inflammation  to  that  of  gan- 
grene, can  scarcely  be  observed ;  bidding  defiance,  very  often,  to  remedies  of  every 
kind.  Indeed,  we  may  remark  it  to  be  the  common  course  with  all  the  diseases 
of  Very  high  excitement,  when  not  under  the  control  of  medical  applications,  to 
terminate  in  the  manner  just  noticed  of  puerperal  fever.  It  was  this  rapid  course, 
with  puerperal  fever  especially,  which  gave  rise  to  the  conflicting  accounts  we 
have  of  its  nature ;  (its  termination  in  gangrene,  or  in  "  putridity,"  as  it  is  cal led,) 
and  which  regulated,  with  too  many,  the  mode  of  treatment  in  the  commencement 
of  the  disease.  The  apprehensions  suggested  by  its  peculiar  termination,  made 
physicians  spare,  or  rather  dread,  the  employment  of  the  only  remedies  capable  of 
preventing  such  an  issue.  Thus,  both  Dr.  Gordon  and  Mr.  Hey,  (indeed,  we 
might  enumerate  others,)  after  they  used,  with  liberal  hand,  blood-letting  and  pur- 
ging, rarely  lost  a  patient.  Dr.  Gordon  did  not  lose  a  patient  out  of  thirty  that 
•were  treated  by  ample  blood-letting  and  liberal  purging;  and  Mr.  Hey  seems  to 
have  been  successful  in  equal  proportion.  The  great  secret  in  treating  such  dis- 
eases as  yellow  fever  and  puerperal  fever,  (at  least,  under  ordinary  circumstances,) 
consists  in  preventing  the  death  of  the  blood  vessels  from  over-excitement,  by 
bleeding,  &c.  Mr.  Hunter  explains  this  by  saying,  "  Debility  begins  very  early, 
because  the  inflammation  itself  is  interfering  immediately  with  the  actions  of  life." 


378  PUERPERAL   FEVER. 

rishment,  large  and  hard  lumps  of  excrement  will  be  sometimes 
discharged,  which  one  might  suspect  to  have  been  confined  in  the 
bowels  a  long  time  before  delivery.  With  regard,  however,  to 
this  symptom,  it  is  very  necessary  to  observe,  that  in  delicate 
constitutions,  great  disturbances  of  the  bowels  are  frequently  oc- 
casioned by  mere  irritation,  which  are  soon  removed  by  the  well- 
timed  exhibition  and  repetition  of  some  cordial  opiate. 

"  There  is  a  peculiarity  in  this  fever,  which  I  believe  has  not 
been  hitherto  observed  or  mentioned.  It  is  an  erysipelatous 
tumour,  of  a  dusky-red  colour,  on  the  knuckles,  wrists,  elbows, 
knees,  or  ankles,  about  the  size  of  a  shilling,  and  sometimes 
larger.  This  is  almost  universally  a  mortal  sign,  and  on  the  in- 
spection of  those  who  have  died  with  this  appearance,  the  dis- 
ease has  been  found  to  have  aifected  the  uterus  principally,  or  its 
appendages. 

"When  this  fever  commences  soon  after  delivery,  and  con- 
tinues its  progress  with  violence  for  a  few  days,  our  hopes  of  a 
favourable  event  will  often  be  disappointed,  and  the  impending 
danger  may  usually  be  foretold  by  the  uninterrupted  progress  of 
the  symptoms,  or  by  returns  of  the  rigour.  A  looseness  imme- 
diately succeeding  the  attack,  though  in  one  sense  it  may  indi- 
cate the  degree  of  disease,  always  contributes  to  its  abatement, 
and  sometimes  proves  critical;  as  does  likewise  a  spontaneous 
vomiting,  sometimes  even  towards  the  last  change,  when  all  hopes 
of  recovery  were  abandoned. 

"  The  profuse  sweat,  which  follows  the  shivering  fit,  has  very 
often  been  completely  critical.  In  some  there  has  been  a  trans- 
lation of  the  disease  to  the  extremities,  where  the  part  has  in- 
flamed, and  a  large  abscess  has  been  formed:  a  similar  abscess 
has  also  in  some  cases  been  formed  on  one  side  of  the  abdomen, 
which  has  been  healed  by  the  most  simple  treatment. 

"Fresh  eruptions  of  the  lochia  are  always  a  favourable  symp- 
tom, and  are  to  be  reckoned  among  the  most  certain  signs  of  amend- 
ment. A  subsidence  of  the  abdomen  after  copious  stools,  and 
with  a  moist  skin,  is  a  fortunate  alteration  for  the  patient;  but 
that  circumstance,  without  evacuations,  and  a  dry  skin,  threaten 
the  utmost  danger."  Introd.  Mid.  Francis's  Ed.  p.  568,  et  seq. 

Dr.  Clarke,  p.  121,  and  other  writers,  have  noticed  a  symptom 
of  a  remarkable  kind,  to  which  we  have  also  borne  witness,  and 
which,  so  far  as  we  have  observed,  has  always  been  a  fatal  one ; 
namely,  the  indifference  of  the  mother  to  the  child,  and  some- 
times even  refusing  to  suckle  it.  From  whence  does  this  indif- 
ference proceed  ?  or  why  should  it  be  a  symptom  of  so  much 
danger  ?x 

1  It  has  lately  fallen  to  my  lot  to  see  a  case  of  completely  developed  puerperal 
fever,  in  which  this  symptom  proved  fallacious.  This  case  will  be  related  pre- 
sently. 


PUERPERAL    FEVER.  379 

Dr.  Clarke,  p.  123,  accounts  for  this  state  of  the  mind  in  an 
ingenious  and  plausible  manner,  by  observing,  "  It  is  probable 
that  the  secretion  of  the  milk  in  the  gland,  and  the  desire  of 
suckling,  may  be  in  some  way  connected  with  each  other,  and 
the  existence  of  the  desire  may  depend  upon  the  presence  of  the 
secretion,  in  like  manner  as  the  power  of  secretion  in  the  testi- 
cles produces  the  passion  for  propagation ;  and  the  passion  in 
its  turn  affects  the  disposition  for  secretion."  But  to  what  cir- 
cumstances shall  we  attribute  this  total  extinction  of  sympathy 
between  parts  so  constantly  in  the  habit  of  exercising  it  ?  Is  it 
owing  to  any  condition  of  the  uterus  itself?  or  does  it  arise  from 
the  peritoneal  inflammation  simply?  or  does  it  require  the  ovaria 
to  be  involved  ?  Is  this  last  conjecture  strengthened  by  the 
fact,  that  the  breasts  become  flaccid  and  waste  away,  when  these 
organs  are  severely  diseased,  wasted,  or  extirpated  ? 

Of  the  Diagnosis. 

The  disease  we  have  been  describing  has  so  many  well-marked 
characters,  that  it  cannot  well  be  confounded  with  any  other  af- 
fection ;  and  we  believe  that  we  may  safely  rely  upon  the  fol- 
lowing symptoms  for  its  diagnosis  : — 

1st.  Pain  or  tenderness  in  the  hypogastric  region,  occur- 
ring after  delivery,  from  the  first  few  hours  to  several 
days.1 
2d.  Swelling  or  tension  in  that  portion  of  the  abdomen 

where  the  pain  or  tenderness  is  felt. 

3d.  By  these  symptoms  almost  always  being  followed  by  a 
chill  or  rigour,  of  longer  or  shorter  duration,  or  greater 
or  less  force. 

1  Mr.  Hey  says  that  the  pain  experienced  by  the  woman,  soon  after  delivery, 
"was  a  very  deceitful  symptom;  and  when  it  was  not  preceded  by  rigour,  occa- 
sioned great  embarrassment  by  the  irregular  manner  of  its  attack;  and  the  conse- 
quent difficulty  of  distinguishing  it  from  after-pains,"  p.  30. 

We  believe  that  the  following  marks  will,  with  much  certainty,  distinguish  the 
pain  of  peritoneal  inflammation  from  that  of  "after-pains." 

1.  After-pains  are  always  alternate,  and  regularly  have  three  periods — a  period 
of  increase,  acme,  and  decline;  they  always  observe  regular  intervals,  be  these 
longer  or  shorter. 

2.  The  pain,  when  occasioned  by  after-pains,  is  never  so  acute;  and  is  confined 
to  the  lower  part  of  the  hypogastric  region. 

3.  There  is  always  more  or  less  discharge  of  the  lochia,  during  the  continuance 
of  the  after-pain,  and  this  without  a  change  in  its  appearance. 

4.  The  mammae  are  not  interrupted  in  their  offices,  if  the  pain  proceed  purely 
from  uterine  contraction. 

5.  If  the  hand  be  laid  upon  the  abdomen,  during  the  pain,  the  uterus  will  be  found 
very  hard  at  one  moment,  and  softer  the  next. 

6.  The  pulse  will  never  be  so  much  accelerated,  as  when  the  peritoneum  is  the 
seat  of  the  disease;  but  both  of  these  pains  may  be  united;  and  when  that  is  the 
case,  the  pain  arising  from  the  contractions  of  the  uterus  offers  no  indication,  as 
it  is  then  of  minor  importance. 


380  PUERPERAL    FEVER. 

4th.  By  the  rigour  being  followed  by  reaction,  terminating, 
for  the  most  part,  in  a  profuse  sweat,  and  without  this 
sweat  moderating  the  fever  or  other  symptoms.1 

5th.  By  this  fever  being  accompanied  by  an  accelerated 
pulse;  rarely  less  than  one  hundred  and  twenty,  and 
oftentimes  as  many  as  one  hundred  and  fifty  or  more 
strokes  in  the  minute. 

6th.  By  the  absence  of  milk  in  the  breasts ;  either  because  it 
has  not  been  secreted,  or  because  the  secretion  has 
been  interrupted. 

7th.  By  a  diminution,  alteration,  or  suspension  of  the  lo- 
chial  discharge.2 

If  a  woman,  within  a  short  period  after  delivery,  be  attacked 
with  the  above  symptoms,  we  may,  we  think,  with  much  safety, 
pronounce  her  to  be  labouring  under  peritoneal  inflammation,  or 
puerperal  fever.  In  this  enumeration  of  symptoms,  we  have 
confined  ourselves  to  the  mention  of  such  only  as  may  be  con- 
sidered as  almost  exclusively  pathognomonic. 

There  are  many  other  symptoms  besides  those  enumerated 
that  attend  this  disease ;  and,  perhaps,  each  individual  case  may 
be  attended  by  some  one  peculiar  circumstance,  which  does  not 
obtain  in  others,  but  which  may  be  dependent  for  its  existence 
upon  some  peculiarity  of  constitution,  or  accidental  cause.  It 
is,  therefore,  impossible  to  anticipate  every  symptom  which  may 
arise  in  any  given  instance.  The  symptoms,  as  detailed  by  Dr. 
Denman,  we  believe,  comprise  every  thing  essential  in  the  his- 
tory of  this  fever,  from  its  formation  to  its  termination.  And 
we  trust,  from  what  has  just  been  laid  down,  that  this  disease 
cannot  well  be  mistaken  for  any  other. 

1  Dr.  Denman,  as  noticed  above,  says  this  sweat  has,  in  many  instances,  proved 
critical. 

*  We  have  elsewhere  remarked  that  Dr.  Leake  says,  "  The  lochia,  from  first  to 
last,  were  not  obstructed,"  p.  52. 

Dr.  Leake's  account  is  of  an  epidemic  puerperal  fever,  which  attacked  the  pa- 
tients of  the  "  Westminster  Lying-in  Hospital,"  and  the  disease,  as  it  appeared 
there,  was  of  a  very  remarkable  character  in  several  important  points ;  and  dif- 
fered from  every  other  of  which  we  have  read  any  account. 

t.  There  was  very  little  pain  in  the  abdomen. 

2.  Very  much  less  frequency  of  pulse. 

3.  The  uterus  almost  invariably  sound. 

4.  Little  change  in  the  powers  or  functions  of  the  mammae. 

5.  No  change  in  the  lochial  discharges. 

6.  The  omentum  being  the  chief  seat  of  disease,  or  found  "melted  down." 
1.  An  unusual  degree  of  headache. 

From  Dr.  Leake's  account,  it  is  evident  that  the  epidemical  constitution  of  the 
air  had  imposed  a  very  mild  character  on  this  disease — its  inflammation  appeared 
to  be  of  the  phlegmonous  kind,  from  the  quantity  of  suppurated  fluid  found  upon 
dissection,  and  from  the  common  expression  of  the  "  omentum  being  melted  down," 
&c.;  and  it  is  farther  evident,  we  think,  that,  had  he  carried  his  bleedings,  &c., 
farther,  he  would  have  cured  all  his  patients. 


PUERPERAL    FEVER.  381 


Of  the  Prognosis. 

There  is,  perhaps,  no  disease,  upon  the  issue  of  which  the 
physician  of  experience  feels  greater  reluctance  to  pronounce 
than  puerperal  fever.  This  unwillingness  proceeds  from  several 
causes,  each  of  which  suggests  the  propriety  of  caution  in  making 
a  decision. 

First,  From  its  very  frequent  tendency  to  a  fatal  result,  even 
under  the  most  prompt,  proper,  and  vigorous  treatment. 

Secondly,  From  the  rapidity  of  its  march  it  gives  but  small 
opportunity  oftentimes  for  the  operation  of  remedies,  even  when 
they  are  applied  early. 

Thirdly,  From  the  impossibility,  very  often,  of  repairing  the 
ravages  a  few  hours'  neglect  has  occasioned,  however  faithfully 
and  properly  the  remedies  may  be  afterwards  employed ;  and, 

Fourthly,  From  the  oftentimes  treacherous  nature  of  the  dis- 
ease, which  will  sometimes  suddenly  terminate  in  death,  when 
circumstances  apparently  promise  recovery. 

These  reasons  should  teach  the  young  practitioner  to  be  ex- 
tremely guarded  in  his  prognosis,  lest  disappointment  follow  im- 
properly raised  hope ;  or  recovery  take  place  when  he  had  caused 
it  to  be  abandoned.  We  may  particularly  caution  him  against 
that  deceitful  amendment  recognised  by  most  writers  on  this  sub- 
ject, which  takes  place  sometimes  as  early  as  the  first  twenty 
hours,  or  as  late  perhaps  as  the  third  day.  Here  the  abatement 
of  pain,  the  diminution  of  the  soreness  of  the  belly,  the  subsiding 
of  the  abdominal  swelling,1  the  less  frequency  of  the  pulse,  seem 
but  the  prelude  to  a  condition,  from  which  no  human  exertion, 
or  power  of  remedy,  seems  capable  of  saving  the  patient. 

Yet  the  symptoms  now  mentioned  are  precisely  those  upon 
which  we  would  build  our  hopes  of  .amendment,  if  not  followed 
by  the  prostration  of  every  power  of  the  system:  consequently, 
it  will  require  much  caution  not  to  be  betrayed  into  error. 

However  promptly  the  disease  may  have  been  met,  even  by 
the  most  suitable  remedies,  the  disease  will,  nevertheless,  some- 
times progress  with  alarming  rapidity.  The  pain  and  swelling 
will  so  augment,  as  to  leave  the  woman  no  choice  of  position  : 
she  finds  a  trifling  mitigation  of  her  sufferings  while  on  her  back, 
with  her  legs  drawn  up,  that  the  abdominal  muscles  may  be  re-" 
laxed.  The  pulse  increases  in  frequency,  but  diminishes  in  force. 
The  respiration  becomes  difficult;  the  tongue  dry,  and  brown,  or 
not  altered,  while  the  face  and  extremities  are  bedewed  with  a 
cold,  clammy  sweat.  The  face  becomes  pale,  or  partially  flushed ; 
the  countenance  haggard,  wild,  and  expressive  of  the  greatest 

1  "  When  the  abdomen  subsides,  without  being  preceded  by  copious  stools,  and 
with  a  dry  skin,  it  threatens  the  utmost  danger."— DENMAN. 


382  PUERPERAL    FEVER. 

distress.     Delirium,  vomiting,1  involuntary  discharges  of  both 
the  fauces  and  urine,  and  death. 

But  before  the  scene  is  finally  closed,  the  woman  seems  to  be 
relieved  of  a  part  of  her  sufferings,  by  a  change  taking  place  in 
some  of  the  more  urgent  and  painful  symptoms.  Distention  is 
diminished,  or  even  sometimes  entirely  removed — the  swelling 
of  the  abdomen  subsides ;  and  pain  ceases  with  more  or  less  sud- 
denness. 

The  absence  of  milk  in  the  breasts,  and  especially  if  this  be 
attended  Avith  an  entire  indifference  to  the  child,  must  be  looked 
upon  as  almost  certainly  fatal.  If  joined  to  these,  there  be  little 
expression  of  suffering,  a  very  quick  pulse,  and  considerable 
swelling;  and  if  the  attack  has  been  very  early  after  delivery, 
the  case  must  be  looked  upon  as  almost  hopeless.  So  uniformly 
is  danger  increased  by  the  earliness  of  the  attack,  that  it  is  no- 
ticed, we  believe,  by  every  writer  upon  the  subject;  therefore, 
this  circumstance  should  always  be  kept  in  view,  when  an  opi- 
nion is  about  to  be  formed  of  the  degree  of  danger. 

The  extent  of  the  abdominal  swelling  seems  to  be  of  more 
consequence  than  the  degree  of  soreness  or  of  pain ;  and  when 
it  is  excessive,  and  becomes  tympanitic,  it  is  extremely  dange- 
rous, nay,  almost  always  fatal.  Dr.  Clarke  says,  "It  has  not 
occurred  in  my  sphere  of  observation,  to  see  any  recover,  in 
whom  the  swelling  of  the  belly  has  been  in  any  very  great  de- 
gree,"2 p.  133.  Also, 

That  "those  who  have  the  disease  at  later  periods  after  deli- 
very are  not  attacked  with  the  same  violence ;  the  depression  of 
strength  is  not  so  great,  the  tumefaction  of  the  abdomen  is  less 
extensive,  and  the  chance  of  recovery  is,  consequently,  better," 
p.  133. 

Dr.  Armstrong  observes,  that  "  an  excess  of  sensibility  is  al- 
ways to  be  dreaded ;  for  I  have  had  opportunities  of  remarking, 
that  those  patients  seldom  recover  who  are  tremblingly  alive  to 
every  surrounding  impression.  It  is  well  known,  that  unmarried 
women  do  not  recover  so  well  as  married  ones ;  the  mental  irri- 
tation, necessarily  attendant  upon  their  situation,  considerably 
increasing  the  febrile  excitement,  and  rendering  them  extremely 
restless,"  p.  26.  Dr.  Clarke  has  remarked  the  same  thing. 

1  We  have  seen  more  than  one  instance  of  puerperal  fever  terminating  in 
"black  vomit,"  similar  to  that  observed  in  "yellow  fever:"  we  have  also  seen 
the  same  appearances  after  rupture  of  the  uterus.  Dr.  Gordon  informs  us,  that 
"when  there  were  symptoms  of  mortification,  what  the  patient  vomited  was 
black,  and  had  a  strong  resemblance  to  coffee  grounds,"  p.  10.  Dr.  Armstrong 
considers  it  as  a  highly  dangerous  symptom,  "  when  there  are  frequent  vomitings 
of  a  cofiee-coloured  fluid,"  p.  31.  Yet  gangrene,  or  mortification,  has  not  been  ob- 
served in  any  of  the  dissections  we  have  read  of. 

*  I  shall  relate  a  case  presently,  in  which  there  was  great  distention  of  the  ab- 
domen, but  where  the  woman  recovered.  Yet  this  must  b»  looked  upon  but  as  a 
rare  exception  to  the  rule. 


PUERPERAL   FEVER.  383 

"Costiveness  is  always  an  unfavourable  circumstance,"  Dr. 
Armstrong  says,  "increasing  in  no  inconsiderable  degree  the 
difficulty  of  cure ;  while  an  open  state  of  the  bowels  before  de- 
livery tends  to  mitigate  the  severity  of  an  early  attack,  and  a 
diarrhoea  coming  on  afterwards,  carries  off  the  disease,"  p.  30. 
Dr.  Denman  says,  as  already  noticed,  that  a  diarrhoea  may  be 
critical,  and  carry  off  the  disease,  p.  568. 

The  signs  which  may  be  looked  upon  as  favourable,  are — 
1st.  A  diminution  of  frequency  of  the  pulse,  with  an  in- 
crease of  its  volume. 

2d.  A  reduction  of  the  swelling  of  the  abdomen,  with  an 

abatement  of  pain ;  provided,  the  first  is  gradual,  and 

the  latter  not  sudden ;  and  accompanied  by  condition 

first. 

3d.  Changing  posture  without  suffering  inconvenience ;  but 

jactitation  must  not  be  mistaken  for  it. 
4th.  A  return  of  milk  to  the  breasts,  attended  by  solicitude 

for  the  child. 

5th.  A  restoration  of  the  lochial  discharge  after  it  has  been 
suppressed;  especially  if  it  change  to  a  healthful  ap- 
pearance. 

6th.  The  tongue  becoming  moist;  losing  its  white  appear- 
ance, and  cleaning  at  the  edges;  or,  if  it  has  been 
brown  and  dry,  becoming  whitish  and  moist,  accom- 
panied by  condition  first. 
7th.  If  the  urine  become  more  abundant,  and  deposits  a 

lateritious  sediment. 

8th.  If  the  skin  become  cooler,  and  moist  throughout  its 
whole  extent ;  especially  if  attended  by  conditions  first, 
second,  third,  fourth  and  fifth ;  or  if  a  natural  warmth 
return  to  the  extremities,  after  having  been  preternatu- 
rally  cold,  accompanied  by  the  signs  just  referred  to. 
9th.  "A  subsidence  of  the  abdomen  after  copious  stools, 
and  with  a  moist  skin,  is  a  fortunate  alteration  for  the 
patient."  Denman. 

10th.  "If  the  pulse  can  be  kept  under  one  hundred  and 
twenty  in  the  minute,  for  the  first  twelve  days,  the  pa- 
tient will  generally  do  well ;  but  if  the  pulse  keep  very 
quick,  after  the  abdominal  symptoms  have  entirely  dis- 
appeared, affections  of  the  chest,1  and  of  the  glandular 
system,  or  deep-seated  suppurations,  may  be  dreaded."2 
Armstrong,  p.  32. 

1  "  If  any  disease  hath  taken  its  immediate  origin,  as  it  were,  out  of  the  puer- 
peral fever,  and  been  combined  with  it,  it  hath  been  the  peripneumony.  I  have 
met  with  several  instances  of  this  kind."  Hulme,  p.  15. 

4  "Some  of  those  who  survived,  recovered  slowly,  and  were  affected  with 
wandering  pains,  and  paralytic  numbness  of  the  limbs,  like  that  of  chronic  rheu- 


384  PUERPERAL    FEVER. 


Of  the  Contagious  Nature  of  Puerperal  Fever.1 

Had  not  the  belief  that  puerperal  fever  was  a  contagious  dis- 
ease, and  had  not  this  belief  a  great  effect  upon  the  minds  of  fe- 
males who  are  pregnant,  or  who  are  in  the  puerperal  state,  and 
consequently  may  very  much  influence  their  happiness,  we  should 
not  have  touched  upon  this  subject;  believing,  as  we  do,  that  the 
opinion  is  altogether  without  foundation,  at  least  in  this  country. 

In  Europe,  and  especially  in  Great  Britain,  this,  and  a  number 
of  other  diseases,  are  believed  to  be  contagious ;  while  in  this 
country  it  only  amounts  to  a  fear,  and  not  to  a  conviction.  The 
disease  in  question,  scarlatina,  erysipelas,  &c.  &c.,  are  in  these 
countries  looked  upon  as  possessing  the  power  of  propagating 
themselves  by  some  specific  quality  of  their  own. 

We  shall  not  attempt  any  formal  refutation  of  the  doctrine  of 
contagion,  by  exhibiting  the  arguments  on  both  sides  of  the  ques- 
tion: we  shall  merely  select  the  opinions  of  such  as  had  ample 
opportunities  to  decide  the  question,  and  whose  conclusions  are 
adverse  to  the  opinion  "that  puerperal  fever  is  contagious." 

Dr.  Hulme,  whose  experience  was  ample,  and  who  has  written 
an  excellent  work  upon  this  disease,  says  that  "  the  puerperal 
fever  is  not  an  infectious  disease,  any  more  than  the  iliac  passion, 
a  pleurisy,  a  nephritis,  or  an  inflammation  in  any  other  part  of 
the  body."  Treatise  on  Puerperal  Fever,  p.  164. 

Dr.  Hull,  whose  opportunities  were  equal,  perhaps,  to  any  who 
may  have  written  upon  this  subject,  says,  "As  far  as  my  obser- 
vation goes,  peritonitis  puerperalis  is  not  infectious.  I  have  never 
seen  a  case,  wherein  I  had  reason  to  suppose  that  the  effluvia, 
arising  from  the  patient,  produced  puerperal  fever,  or  typhus,  or 
any  other  disease  in  another  person,  either  directly  or  indirectly. 
The  disease  in  question  frequently  arises  where  there  is  not  the 
least  foundation  for  a  suspicion  that  infection  has  been  applied," 
p.  248. 

Mr.  Hey  appears  strongly  inclined  to  the  opinion  that  puer- 
peral fever  is  not  contagious ;  but  seems  afraid  to  decide  abso- 
lutely upon  the  question. 

In  this  country,  under  no  circumstance  that  puerperal  fever 
has  appeared  hitherto,  does  it  afford  the  slightest  ground  for  the 
belief  that  it  is  contagious.  In  this  city,  so  far  as  we  know,  it 
has  always  shown  itself  as  a  sporadic  disease;  and  in  this  form, 

matism.  Some  had  critical  abscesses  in  the  muscular  part  of  the  body,  which 
were  a  long  time  coming  to  suppuration,  and  when  broke,  discharged  a  sanious 
ichor."  Leake,  vol.  ii.  p.  56. 

1  "By  contagion,  is  understood  effluvia,  arising  directly  or  indirectly  from  the 
human  body  under  particular  diseases,  and  capable  of  exciting  the  same  disease  in 
other  persons  to  whom  it  may  be  applied."  Hull,  p.  247. 


PUERPERAL    FEVER.  385 

it  has  never  been  looked  upon  as  contagious,  except  by  Dr.  Arm- 
strong. He  says,  "The  peritonitic  fever,  when  completely 
formed,  is,  in  kind,  though  not  in  degree,  as  contagious  as  the 
epidemic :"  in  this  sentiment  he  stands  alone  ;  not  even  support- 
ed by  those  who  believe  in  the  contagious  power  of  the  epidemic. 
In  Northumberland,  in  this  state,  (see  p.  350,)  where  it  was  epi- 
demic, there  was  no  evidence  that  it  was  contagious.  Dr.  Leake 
says,  decidedly,  the  sporadic  puerperal  fever  is  not  infectious; 
and  it  is  only  so,  when  epidemic,  under  particular  circumstances, 
vol.  ii.  p.  140. 

Now,  it  would  be  very  extraordinary  to  declare,  for  it  would 
obtain  no  belief,  that  sporadic  small-pox,  measles,  or  hooping- 
cough,  were  not  contagious ;  for  we  must  ask,  what  is  the  differ- 
ence between  the  sporadic  form  or  quality  of  a  disease,  and  the 
epidemic  form  or  quality  of  a  disease ;  except  that  the  latter  has 
its  type  affected  by  some  occult  influence  in  the  air,  which  gives 
rise,  at  the  same  time,  to  the  epidemic  prevalence  of  the  disease? 


g.   Treatment. 

We  have  now  to  consider  the  most  important  part  of  our  sub- 
ject, namely,  the  treatment.  As  regards  this,  much  discrepancy 
must  necessarily  prevail,  as  scarcely  any  two  authorities  can 
have  viewed  the  disease  under  the  same  aspect,  as  the  disease  is 
so  variously  modified.  In  confirmation  of  this,  it  is  only  neces- 
sary to  refer  to  the  late  researches  upon  this  point — we  say  the 
late  researches,  as  we  believe  these  to  be  very  much  the  most  to 
be  relied  upon.  We  do  not  wish,  however,  to  be  understood  as 
conveying  any  oblique  censure  upon  former  observation ;  we  only 
mean,  that  pathological  inquiries  are  now  conducted  with  much 
more  care  and  with  much  more  success,  than  thirty  or  forty  years 
ago.  For  improvements  in  this  highly  interesting  and  important 
study,  we  are  particularly  indebted  to  the  French,  and  especially 
since  the  writings  of  Bichat  have  made  us  acquainted  with  the  in- 
dependent and  important  role  that  each  separate  tissue  performs. 
We  do  not  pretend  that  the  same  phenomena  did  not  present 
themselves  to  former  autoptic  inquirers — we  only  declare  they 
were  not  so  well  understood  and  defined.  This  fact  can  be  very 
easily  proved  by  a  reference  to  some  of  the  most  careful  exa- 
miners of  bodies  dead  from  puerperal  fever.  Let  us  take  Drs. 
Leake,  Gordon,  and,  above  all,  the  accurate  and  faithful  Clarke, 
as  illustrative  of  the  position  now  advanced,  and  it  will  be  per- 
ceived, that  no  distinction  is  made  between  the  parenchyma  of 
the  uterus  or  ovaries,  and  their  peritoneal  coverings,  as  seats  of 
disease ;  for  were  this  membrane  inflamed,  had  it  suppurated,  or 
were  it  gangrenous,  the  uterus  or  the  ovaries  were  said  to  be  in 

25 


386  PUERPERAL     FEVER. 

either  of  these  conditions ;  being  altogether  ignorant  that  the  pe- 
ritoneum covering  these  parts  may  be  in  a  pathological  condition, 
without  implicating  the  other  structures  of  these  organs.  Again, 
pus  has  been  found  in  various  portions  of  the  uterus,  when  it 
was  cut  into :  this  pus  was  supposed  to  be  the  result  of  the  in- 
flamed parenchyma  of  this  body ;  for  they  were  not  aware  this 
fluid  was  produced  by  suppuration  of  the  internal  mucous  coat 
of  the  veins.  Again,  the  uterus  was  often  declared  to  be  in  a 
state  of  gangrene  from  puerperal  fever;  but  modern  research 
has  proved  that  this  organ  maybe  "softened,"  (ramollissement,) 
and  this  without  any  particular  tendency  to  putrefaction.  And 
once  more,  that  phlebitis  of  the  uterine  veins  gives  a  typhoid 
character  to  the  accompanying  fever,  &c.,  for  we  could  easily 
extend  examples. 

Now,  it  is  rendered  every  way  probable  that  some  occult  cause 
may  operate  to  produce  a  particular  tendency  in  some  one  tissue 
or  other,  to  become  the  seat  of  the  disease :  thus,  we  find  in  some 
instances  the  peritoneum  to  be  the  principal  seat  of  disease ;  and 
this,  upon  certain  portions  of  it,  (see  our  history,  &c.,  of  this  dis- 
ease,) in  other  cases,  the  parenchyma  of  the  uterus  is  especially 
attacked;  or  its  veins,  or  its  lymphatics,  and  perhaps  even  its 
nerves ;  and  each  variety  giving  a  particular  character  to  the 
phenomena  of  the  disease — hence,  as  we  have  already  observed, 
puerperal  fever  is  considered  by  Conquest  and  some  of  the 
French  writers,  as  a  generic  term.  See  page  347,  &c.  It  must, 
therefore,  be  evident,  if  these  observations  be  correct,  that  much 
practical  acumen  is  necessary  to  the  successful  treatment  of  this 
disease,  that  the  different  forms  may  not  be  confounded — it  is, 
also,  equally  evident,  that  we  have  much  to  learn  in  diagnosis. 
However,  let  it  be  understood,  that  though  puerperal  females  in 
this  country  must  necessarily,  like  those  of  Europe,  be  obnox- 
ious to  remote  causes ;  yet  that  here  such  causes,  be  they  what 
they  may,  tend  more  frequently  to  the  production  of  a  pure  in- 
flammatory condition  of  the  peritoneum,  than  the  same  causes  do 
in  other  portions  of  the  globe.  We  say  more  frequently,  for  this 
does  not  appear  to  be  the  case  uniformly — for,  in  the  late  in- 
stances in  the  Pennsylvania  Hospital,  we  believe  that  all  who 
were  attacked  died,  notwithstanding  the  most  prompt  and  active 
antiphlogistic  means  were  pursued.  In  these  cases  it  must  be 
evident  that  some  local  but  inscrutable  cause  operated,  as  no 
such  condition  of  liability  was  observed  in  private  practice. 

From  these  statements,  it  will  be  understood  that  no  one  mode 
of  treatment  can  be  applicable  to  every  epidemic  visitation  of 
puerperal  fever,  or  even  every  sporadic  case ;  and,  with  a  view 
to  establish  this  point  more  firmly,  we  shall  give  the  experience 
of  Professor  Desormeaux  and  his  pupil,  M.  Tonnelle,  upon  this 
point,  though  we  are,  at  the  same  time,  persuaded  that,  in  this 


PUERPERAL   FEVER.  38T 

country,  and  in  private  practice,  the  disease  is  almost  uniformly 
highly  inflammatory. 

From  the  views  entertained  by  Desormeaux  of  this  disease,  he 
was  led  to  adopt  several  different  modes  of  treatment,  the  result 
of  which  he  has  given,  together  with  the  successes,  and  this  at 
several  seasons  of  the  year;  for  this  gentleman  found,  that  a 
mode  of  treatment  which  may  have  been  successful  at  one  pe- 
riod, might  not  prove  so  at  another.  Among  the  more  active 
remedies  he  used,  we  may  reckon  general  bleeding,  leeching, 
ipecacuanha,  emetics,  salivation:  the  auxiliary  means  were, 
warm  hip-bath,  laxatives,  enemata,  bark,  cataplasms,  and  emol- 
lient washes  for  the  uterus. 

The  contradictory  means,  as  laid  down  by  authors,  for  the  cure 
of  this  disease,  induced  M.  Desormeaux  to  give  fair  trial  to  such 
as  came  recommended  by  good  authority ;  and,  not  to  remain 
satisfied  by  either  success  or  failure,  he  tried  the  same  means  at 
different  seasons  of  the  year.  General  blood-letting  was  often 
found  highly  useful  as  the  initial  remedy,  as  it  was  found  impe- 
riously demanded  by  the  violent  action  of  the  system,  in  cases 
that  he  judged  to  be  purely  inflammatory ;  but,  for  the  most  part, 
this  benefit  was  limited  to  the  early  stage  of  these  cases,  as  it 
failed  to  subdue  the  local  inflammation,  and  was  often  of  ques- 
tionable utility,  as  this  first  stage  so  quickly  ran  its  course.  On 
this  account,  local  bleeding  was  resorted  to,  to  overcome  the 
local  affection  of  the  uterus  and  its  appendages — forty  or  fifty 
leeches  were  applied  to  the  abdomen,  and  these  followed  by  a 
hip-bath,  or  poultice,  and  this  was  sometimes  repeated  two  or 
three  times  in  thirty-six  or  eight  and  forty  hours.  When  this 
plan  proved  successful,  it  was  speedily  followed  by  a  copious 
perspiration.  But  the  good  effects  of  this  method  were  confined 
to  the  early  stage,  and  previous  to  suppuration.  He  estimates  the 
rate  of  success  in  the  following  manner.  Of  165  cases  treated 
by  general  and  local  blood-letting,  three-fourths  recovered. 

Ipecacuanha,  as  an  emetic,  he  states,  was  only  used  in  the 
early  stage :  this  was  sometimes  successful,  and  at  other  times 
not,  depending  upon  seasons,  as  he  supposes.  However,  of  forty 
cases  treated  by  it,  four-fifths  recovered.  This  remedy  was  not 
useful  after  the  suppurative  stage  had  taken  place ;  nor  was  it 
found  to  answer  in  the  typhoid  type  of  this  disease.  For  the 
suppurative  stage,  or  the  typhoid  variety  of  this  disease,  MM. 
Desormeaux  and  Tonnelle  think  they  have  found  an  important 
remedy  in  mercurial  salivation ;  for,  though  by  far  the  greater 
number  of  such  cases  must  prove  fatal,  still,  if  salivation  in- 
creases the  number  that  get  well,  it  must  be  looked  upon  as  a 
valuable  therapeutic  means;  and  perhaps  we  should  have  the 
more  confidence  in  this  plan,  since  the  inveterate  prejudices  of 
the  French  against  the  use  of  mercury,  would  not  permit  them 


PUERPERAL   FEVER. 

to  employ  it,  without  having  derived  advantage  from  it  in  their 
trials.  We  have  directed  attention  to  this  remedy,  (see  page 
414,  on  mercurial  frictions.)  Mercury  was  only  used  in  the 
advanced  stage  of  inflammatory  puerperal  fever,  or  in  typhoid 
cases,  or  where  neither  blood-letting,  or  leeching,  or  ipecacuanha 
would  be  useful.  It  was  used  in  form  of  ointment — two  ounces 
were  rubbed  in  every  twenty-four  hours — the  abdomen  and 
thighs  were  the  parts  selected.  The  auxiliary  remedies  men- 
tioned above  were  thought  to  be  useful,  especially  emollient 
injections,  once  in  six  hours.  This  mode  of  treating  any  one 
disease  is  too  exclusive  to  be  absolutely  relied  on ;  as  the  suc- 
cessful cases  may  not  have  been  such  from  the  peculiar  treat- 
ment, but  from  their  want  of  intensity ;  and  therefore  might  have 
yielded  to  either  plan  adopted  by  Desormeaux  and  Tonnelle, 
while  the  unsuccessful  instances  may  have  proved  such  from 
their  overwhelming  violence,  or  from  delay,  rather  than  from 
the  particular  treatment  being  inefficient.  It  is  necessary  to  the 
establishment  of  any  exclusive  mode,  that  all  the  patients  should 
be  as  nearly  as  possible  in  the  same  condition,  when  the  plan  ia 
first  put  in  execution.  Therefore,  any  plan  may  be  either  only 
more  or  less  useful,  or  otherwise  quo  ad  hoc. 

Most  of  the  errors  on  the  subject  of  puerperal  fever  have  arisen 
from  a  want  of  the  necessary  discrimination  between  the  stages 
of  this  disease,  and  to  an  ignorance  that  the  peculiarity  of  the 
subsequent  ones  are  entirely  dependent  upon,  or  only  the  neces- 
sary and  inevitable  consequences  of,  the  first  stage.1  Few  have 
so  far  shut  their  eyes  against  the  facts  revealed  by  dissections,  as 
not  to  admit  that  its  first  stage  is  that  of  high  inflammation.  But, 
as  this  inflammation  runs  its  course  rapidly,  and  is  succeeded 
either  by  a  gangrenous  tendency,  or  an  effusion  of  large  quan- 
tities of  serum  in  the  cavity  of  the  abdomen,  and  as  the  body, 
quickly  after  death,  manifests  a  strong  disposition  to  decompo- 
sition, it  was  thought  by  many,  that  the  disease,  from  its  com- 
mencement, had  a  strong  septic  tendency;  and  remedies  were 
employed  to  guard  against  the  consequences,  rather  than  for  the 
removal  of  the  cause;  namely,  the  first  or  inflammatory  stage.2 

1  Dr.  Armstrong,  Facts  and  Observations,  &c.,  p.  60,  says,  "  The  first  stage  " 
of  Puerperal  Fever,  "  is  marked  by  highly  inflammatory,  the  second,  by  highly 
typhoid  characters;  and  it  has  always  appeared  to  me,  that  the  tendency  to 
putridity  in  the  latter  was  proportionate  to  the  degree  of  inflammation  in  the 
former." 

Dr.  Denman  says,  "  When  the  fever  has  remained  for  a  very  few  days,  the 
putrid  symptoms,  which  are  usually  according  to  the  degree  of  the  preceding  in- 
flammation, advance  very  rapidly."  We  repeat  these  observations,  because  of 
their  unquestionable  truth,  and  practical  value. 

'"I  cannot  help  suspecting,"  says  Dr.  Armstrong,  "that  some  distinguished 
authors,  having  formed  their  opinion  from  the  appearance  of  the  disease,  and  the 
ill  effects  of  venesection,  at  this  period,  (the  gangrenous,)  have  thus  been  per- 
suaded that  debility  is  the  principal  thing  to  be  counteracted  from  the  beginning, 


PUERPERAL   FEVER.  389 

To  prove  this,  let  the  treatment  and  the  result  of  the  plans  of 
Denman,  Gordon,  Hey,  Armstrong,  and  even  Leake,  be  con- 
trasted with  the  mistaken  practice  of  Clarke,  and  some  others. 
In  the  practice  of  the  first  of  these  gentlemen,  recoveries  were 
common ;  in  that  of  the  latter,  very  few  escaped.  Dr.  Clarke  in- 
forms us,  that  three  out  of  four  died,  p.  132.  The  patients  un- 
der his  care  were  treated,  from  the  beginning,  with  large  doses 
of  bark,  and  such  other  remedies  "  as  have  a  tendency  to  support 
the  strength,  and  diminish  the  irritability." 

It  may  be  said,  that,  in  the  epidemic  described  by  Dr.  Clarke, 
there  was  but  little  evidence  of  inflammation,  and  much  of  *'  pu- 
tridity;" but  this  should  not  be  too  hastily  assumed,  as  we  have 
attempted  to  prove  at  p.  360.  Nor  can  an  inference  be  drawn 
in  favour  of  his  pathological  views  from  the  success  of  his  prac- 
tice. The  public  are  much  indebted  to  Dr.  Denman  for  the  can- 
did renunciation  of  his  errors  upon  this  subject.  In  the  early 
part  of  his  practice,  he  entertained  great  doubts  of  the  propriety 
of  blood-letting  in  puerperal  fever:  he  thought  it  weakened  the 
patient,  without  lessening  the  disease ;  and  for  a  long  time,  he 
informs  us,  he  did  not  take  away  blood  in  any  quantity. 

The  influence  of  this  highly  cultivated  and  respectable  practi- 
tioner was  so  great  as  to  give  tone  to  public  opinion ;  his  mode 
of  practice  and  his  views  were  extensively  adopted  by  the  British 
practitioners;  and  they  became  almost  the  standard  for  the  treat- 
ment of  puerperal  fever.  Fortunately  for  the  fate  of  hundreds, 
a  more  extended  experience,  and  more  correct  notions  of  tne 
nature  of  the  disease,  led  him  to  renounce,  with  much  magnani- 
mity, the  errors  of  his  early  life.  Therefore,  so  soon  as  he  was 
convinced  of  the  insufficiency  or  total  inefficacy  of  his  plan,  he 
gave  it  up  with  a  candour  which  all  must  admire,  though  few 
may  imitate  if.  He  says,  in  the  last  edition  of  his  works,  as 
edited  by  Dr.  Francis,  p.  576— 

"I  am  now  convinced,  by  manifold  experience,  that  my  reason- 
ing was  fallacious,  and  my  fears  groundless;  and  that  what  I  had 
considered  as  proofs  of  insufficiency  or  impropriety,  of  bleeding, 
in  the  true  inflammatory  puerperal  fever,  ought  in  reality  to  have 
been  attributed  to  the  neglect  of  performing  it  in  an  effectual 
manner,  at  the  very  beginning  of  the  disease.  In  short,  if  the 
first  stage  be  permitted  to  pass  unheeded,  bleeding  will  then  cer- 
tainly be  injurious,  the  opportunity  having  been  lost;  and  the 
physician  called  in  afterwards,  however  great  his  talents  may  be, 
will  too  often  have  the  mortification  of  being  the  spectator  of 

and  during  the  whole  course  of  the  fever.  Be  this  as  it  may,  the  stimulant  treat- 
ment is  at  once  the  most  delusive  and  dangerous  which  can  be  adopted ;  and  it  is 
much  to  be  lamented  that  it  has  the  weight  and  authority  of  some  eminent  names." 
— Facts  and  Observations,  p.  63. 


PUERPERAL    FEVER. 

mischief  which  he  cannot  then  remedy,  and  an  event  which  he 
can  only  deplore." 

We  are  told,  that  it  is  of  the  utmost  consequence  to  the  cure  of 
this  disease,  that  we  distinguish  between  the  true  inflammatory 
and  the  putrid  puerperal  fever.  This  would  be  most  true  and 
important,  did  such  a  difference  really  exist  as  is  here  intimated; 
but  the  distinction  attempted  has  been  based,  we  believe,  upon 
the  violence  of  the  complaint  at  different  times,  and  under  different 
circumstances,  rather  than  upon  any  essential  difference  in  the 
absolute  nature  and  seat  of  the  diseases.  See  note  to  p.  369. 

Thus  the  sporadic  puerperal  fever  is  more  easily  subdued,  and 
will  bear  bleeding  even  at  a  later  period  than  the  epidemic  puer- 
peral fever ;  because  the  former  is  less  rapid  in  its  course,  owing 
to  the  accompanying  inflammation  being  less  exalted;  and  not  to 
the  latter  being  of  a  putrid  character ;  for  when  this  state  exists, 
we  must  repeat  it,  it  is  owing  to  the  inflammation  being  so  tran- 
scendent, that  the  parts  must  die,  if  not  speedily  relieved. 

And  though  the  system,  under  such  circumstances,  cannot 
bear,  perhaps,  the  abstraction  of  blood,  yet  it  cannot  support  the 
action  of  stimuli.  We  are  persuaded  there  are  few  errors  in 
practice  greater  than  that  founded  on  the  belief  that  when  a 
disease  will  not  bear  depletion  with  profit,  that  it  then  absolutely 
requires  the  opposite  treatment;  arid  we  are  sure  it  has  been  the 
death  of  thousands. 

The  supposed  tendency  to  typhus  in  fevers  of  every  description, 
when  the  patient  has  become  weak,  and  especially  if  the  tongue 
has  become  brown  or  dry,  has  led  unhappily  to  the  use  of  tonic 
and  stimulating  remedies,  by  far  too  many  practitioners ;  for  were 
the  results  of  such  treatment  faithfully  recorded,  we  are  convinced 
there  would  be  but  little  evidence  in  its  favour — indeed,  so  con- 
fident are  we  on  this  subject,  that  we  never  fail  to  consider  the 
cures  of  such  a  state  of  fever  by  this  method,  but  as  escapes. 

Let  us  illustrate  the  position  we  have  assumed,  by  taking  part 
of  cases  IX.  p.  89,  and  XXVII.  p.  206,  as  related  by  Mr.  Hey. 
On  the  tenth  day  of  this  patient's  disease,  it  is  said,  "  She  had 
had  no  sleep  in  the  night,  and  was  very  restless,  with  some  de- 
gree of  delirium.  We  found  her  incessantly  talking,  but  could 
procure  no  answer  from  her  to  any  question  that  was  proposed. 
She  refused  all  medicine.  Pulse  one  hundred  and  twenty. 

"In  the  course  of  the  day,  the  abdomen  became  tumid,  from 
flatus  confined  in  the  bowels :  the  tumefaction  was  unattended 
by  pain  or  soreness,  and  entirely  subsided  as  soon  as  evacuations 
were  procured  by  an  injection. 

"Ten,  P.  M.  she  was  in  all  respects  worse.  Her  urine  came 
away  involuntarily ;  she  had  some  rattling  in  her  breathing,  and 
appeared  to  be  sinking.  Pulse  one  hundred  and  thirty-two. 


PUERPERAL    FEVER.  391 

Thirty  drops  spt.  aether,  sulph.  were  ordered  to  be  given  now  and 
then  as  a  grateful  cordial. 

"29th,  (eleventh  day  of  illness,)  we  were  agreeably  surprised 
to  find  our  patient  much  better.  During  the  night  she  had  been 
able  to  retain  her  urine,  and  had  made  a  large  quantity  with 
proper  intervals.  She  was  quite  sensible,  and  more  composed  ; 
and  had  regained  the  power  of  putting  out  her  tongue,  which  be- 
fore she  had  lost.  Pulse  one  hundred  and  six,  and  the  tongue 
continued  clear.  Ordered  to  take,  at  regular  intervals,  a  draught 
of  infus.  rosse,  made  with  decoct,  cinchonas,  and  to  have  occa- 
sionally Madeira  wine. 

"These  favourable  symptoms  did  not  long  continue.  In  the 
evening  the  pulse  got  up  to  one  hundred  and  twenty,  and  the 
heat  had  increased. 

"  From  this  time  the  patient  became  gradually  weaker,  her 
pulse  was  accelerated  more  and  more,  and  her  urine  was  again 
discharged  involuntarily.  She  lived  two  days  in  a  state  of  great 
anxiety  and  increased  restlessness,  and  died  on  Sunday  night, 
the  1st  of  July,"  that  is,  on  the  15th  day  of  the  disease. 

On  this  case,  so  far  as  we  have  related,  we  shall  offer  a  few 
remarks:  on  the  eleventh  day  of  this  patient's  illness  she  was 
found  to  be  surprisingly  improved;  all  the  favourable  circum- 
stances, which  usually  announced  the  decline,  or  almost  absence 
of  the  disease,  were  present.  She  was  able  to  retain  her  urine, 
and  which  she  made  abundantly  and  properly,  after  its  having 
passed  from  her  involuntarily ;  she  was  sensible,  after  having  been 
incoherent  and  stupid ;  her  tongue  became  clean,  and  her  pulse 
was  reduced  from  a  hundred  and  thirty-two  to  a  hundred  and  six. 
She  had  regained  the  power  of  putting  out  her  tongue,  "which 
before  she  had  lost." 

The  day  previously  to  this  amendment  she  was  extremely  ill, 
as  above  stated ;  she  was  then  ordered  the  spt.  aether,  sulph.  in 
small  but  repeated  quantities.  Now,  is  it  not  evident  that  the 
amendment  of  this  patient  was  owing  to  her  being  only  very 
moderately  stimulated  by  the  aether  ?  a  stimulus  at  the  moment, 
in  point  of  power,  exactly  suited  to  the  condition  of  the  system ; 
and  had  the  physicians  been  contented  to  "let  doing  well  alone," 
it  is  probable  she  would  have  recovered.  But,  over-anxious  for 
their  patient,  they  must  prescribe  several  stimuli  at  once ;  namely, 
bark,  wine,  &c.,  and  thus  undo  in  a  moment  all  they  have  so  hap- 
pily achieved  by  their  previous  moderation ;  for  Mr.  Hey  informs 
us,  that  "  these  favourable  symptoms  did  not  continue  long."  In 
this  case  the  system  was  evidently  over-stimulated,  and  the  patient 
succumbed ;  for,  had  a  free  use  of  opium  been  made,  it  would,  we 
think,  have  been  the  congenial  stimulant,  for  this  article  never 
acts  more  favourably  than  in  peritoneal  inflammation  after  ample 
Depletion.  Indeed  in  many  other  inflammations,  we  have  seen 


392  PUERPERAL    FEVER. 

its  salutary  influence  when  the  other  diffusible  stimuli  would  have 
proved  most  probably  injurious. 

It  may  be  said  that  these  favourable  appearances  now  and  then 
take  place,  yet  disappoint  the  hopes  they  have  created — this  may 
be  the  case  in  the  early  stage  of  the  disease;  but  when  these 
changes  take  place  so  late  as  the  llth  day,  we  should  be  disposed 
to  look  upon  them  as  announcing  a  return  to  health ;  and  had 
this  amendment  been  properly  cherished,  it  might  have  termi- 
nated in  it ;  especially  as  the  pulse  was  so  much  reduced  in  fre- 
quency as  to  be  at  a  hundred  and  six  in  a  minute. 

Case  XXVII.  united,  on  the  8th  and  9th  days,  as  many  bad 
symptoms  as  are  generally  recorded  upon  such  occasions ;  that  is, 
"the  pulse  became  more  frequent,  and  the  patient  appeared 
more  sunk.  The  abdomen  remained  much  tumefied,  but  mani- 
fested but  little  sensibility  upon  pressure.  She  still  complained 
chiefly  of  the  pain  in  her  head." 

On  the  10th  day,  says  Mr.  Hey,  "I  accompanied  the  surgeon 
in  the  evening  to  visit  his  patient.  She  appeared  very  low,  and 
her  pulse  was  frequent  and  feeble.  Her  tongue  was  dry  and 
brown,  and  her  teeth  were  incrusted  with  sordes.  Her  head  was 
yet  affected  with  pain,  but  she  made  but  little  complaint  of  her 
belly.  It  was,  however,  enlarged,  and  though  not  very  tender, 
was  sensible  to  pressure.  The  symptoms  of  active  inflamma- 
tion having  given  place  to  those  of  a  typhoid  character,  the  pur- 
gatives had  been  omitted,  and  the  evacuations  had  consequently 
decreased.  I  recommended  such  a  repetition  of  the  purgative  as 
might  procure  an  evacuation  about  once  in  four  hours,  and  a 
continuation  of  the  saline  mixture  in  a  state  of  effervescence.  The 
strength  of  the  patient  was  supported  by  a  light,  but  nutritious 
diet,  such  as  broths,  jellies,  chocolate,  and  milk. 

This  plan  was  regularly  pursued  for  four  days,  and  the  patient 
was  then  convalescent. 

This  case  is  full  of  valuable  instruction  in  the  treatment  of  this 
disease,  and  indeed  of  every  other,  where  there  is  what  is  termed 
a  "  tendency  to  typhus."  It  must  be  observed,  that  on  the  tenth 
day  of  the  disease,  there  was  what  Mr.  Hey  himself  considered 
a  "typhoid  character:  the  tongue  was  dry  and  brown,  and  there 
was  great  weakness."  Yet,  notwithstanding  these  evidences,  he 
did  not,  as  in  the  former  case,  goad  the  system  to  dissolution, 
by  bark,  wine,  and  other  stimuli ;  on  the  contrary,  he  gave  the 
system  an  opportunity  of  righting  itself,  by  the  abstraction  of 
offensive  matters  from  the  bowels ;  and  though  he  says  he  had 
omitted  the  purgatives,  he  yet  "  contrived  to  have  a  stool  once 
in  four  hours." 

Now,  will  any  dreader  of  typhus  permit  his  patient  to  have 
six  stools  per  diem,  or  give  the  neutral  mixture  by  way  of  cor- 
dial? Certainly  he  will  not — he  will  put  bark,  wine,  ammonia, 


PUERPERAL    FEVER.  393 

&c.,  &c.,  in  immediate  requisition;  and  be  rewarded  for  his  anx- 
iety and  exertions  by  the  loss  of  his  patient.  There  is  not  the 
smallest  doubt  upon  my  mind,  that  Mr.  Hey  would  have  lost  the 
patient  last  mentioned,  as  certainly  as  he  did  the  other,  had  he 
had  recourse  to  the  same  remedies.1 

It  is  truly  a  matter  of  surprise,  that  Dr.  Leake  did  not  profit 
more  by  his  experience  in  the  fever  of  the  "Westminster  lying- 
in  Hospital;"  and  by  the  freer  use  of  the  lancet,  have  saved  most 
probably  more  patients  than  his  account  of  cases  now  exhibits. 
We  have  thought  proper  to  make  a  scale  of  these  cases,  to  show 
that  the  disease  he  had  to  encounter  was  comparatively  a  mild 
one,  and  would  most  probably  have  yielded  in  almost  every  in- 
stance to  a  more  liberal  plan  of  depletion.  Dr.  Leake  had  cer- 
tainly a  correct  notion  of  the  nature  of  the  disease ;  as  his  dissec- 
tions displayed  to  him  in  every  instance  the  ravages  of  previous 
inflammation.  Why  his  hand  was  withheld  from  the  lancet,  it  is 
impossible  to  say ;  for  had  he  examined  the  result  of  his  own 
practice  he  must  have  perceived  that  the  only  instances  of  reco- 
very, (at  least  of  those  he  has  recorded,)  were  those  in  which 
bleeding  and  purging,  to  a  greater  or  less  extent,  were  employed ; 
and  not  a  single  instance  of  recovery  when  it  was  not  employed. 
We  have  the  histories  of  eighteen  cases,  the  terminations  of 
which  were  as  follow,  viz.: — 

Cases  I.  II.  VII.  V.III."  IX.  XII.  XV.  XVI.,  were  bled  and  purged,  and 

recovered. 

IV.  Bled  ^viij.  on  or  about  the  seventh  day,       .         .         died. 

V.  Bled  ^vj.  on  the  third  day,  «•   >••+  •'    '.  :  '   »;-:<i  «'•''    died. 

XI.  Bled^vij.  on  the  third  day,      >   \    .1  .-*•  -.'. .%•,•!',»-  •*     died. 

VI.  VIII.  X.  XIII.  XIV.  XVII.  XVIII.3  not  bled,       y  ,,,,      died. 

This  little  schedule  speaks  volumes  as  to  the  comparative 
modes  of  treatment.  Out  of  the  eleven  patients  which  were  bled, 
eight  recovered ;  and  of  the  three  who  died,  it  may  be  truly  said, 
the  bleeding  could  not  be  expected  to  have  been  successful, — 
for  it  was  employed  both  sparingly  and  late.  Case  IV.  was 
seen  by  Dr.  Hunter  in  private  practice ;  and  he  thought  from  the 
nature  of  the  symptoms,  it  would  be  giving  a  chance  to  extract 
blood  on  the  seventh  or  eighth  day.  This  circumstance  shows 

1  We  are  not  informed,  however,  by  Mr.  Hey,  of  the  motives  which  induced 
him  not  to  employ  the  common  routine  of  stimuli  for  his  patient ;  but  this  is  of 
no  consequence  as  regards  the  event,  as  it  establishes  the  principle  insisted  on; 
namely,  that  though  a  patient  may  not  bear  the  loss  of  blood,  or  sustain  other 
evacuations  to  the  extent  they  had  previously  been  employed,  yet  that  she  will 
bear  them  to  a  certain  extent ;  and  that  she  will  sink  under  the  action  of  stimuli, 
when  urged  beyond  a  very  moderate  degree. 

Q  It  may  be  proper  to  notice  that  case  VIII.  is  not  case  VIII.  in  Dr.  Leake's 
series  :  it  is  included  under  the  history  of  case  VII. 

*  This  case,  like  case  VIII.  mentioned  above,  is  also  recorded  in  the  history  of 
case  VII.  See  Treatise  on  Child-bed  Fever,  Vol.  II. 


394  PUERPERAL    FEVER. 

the  comparative  mildness  of  the  disease  as  it  then  appeared;  and 
Dr.  Leake  informs  us,  p.  57,  that  "when  the  disease  proved 
mortal,  the  patient  generally  died  on  the  tenth  or  eleventh  day 
from  the  attack;  consequently  it  should  be  looked  upon  as  one  of 
a  mild  type." 

In  the  epidemic  so  well  described  and  so  successfully  treated 
at  Leeds  by  Mr.  Hey,  the  success  was  still  greater,  though  the 
disease  was  of  much  greater  malignity.  For  we  are  informed 
by  Mr.  Hey,  that  "it  was  by  no  means  uncommon  for  the  fever 
at  Leeds  to  finish  its  course  in  forty-eight  hours :  and  in  many 
cases,  it  proved  fatal  in  a  much  snorter  time,"  p.  165.  Yet, 
the  success  following  the  plan  pursued  by  Mr.  Hey  was  consi- 
derably greater  than  that  which  attended  Dr.  Leake,  in  a  much 
milder  form  of  the  disease ;  and  this  success  was  owing  to  a 
bolder  practice,  and  one  better  adapted  to  the  nature  of  the 
complaint. 

Mr.  Hey  states  that  "of  fourteen  patients  treated  without 
bleeding,  only  three  recovered,"  p.  165.  And  farther,  that  after 
"I  had  determined  to  use  bleeding  in  addition  to  purging,  of 
thirty-three  patients  whom  we  (he  and  his  father)  attended,  only 
three  died;  the  last  twenty-six  having  recovered  in  uninterrupted 
succession;"  to  this  he  adds,  in  a  note,  copious  bleeding  was 
used  in  all  these  cases  except  one,  which  was  rather  slight,  and 
was  cured  by  purging  alone,  p.  168. 

At  Sunderland,  where  the  disease  was,  perhaps,  rather  less 
malignant  than  at  Leeds,  Dr.  Armstrong  says,  "  Those  patients 
who  were  copiously  bled  and  purged,  and  vomited  successively, 
were  usually  convalescent  on  the  fourth  or  fifth  day,  and  from 
that  time  regained  their  health  and  strength  rapidly,"  p.  73. 

He  says,  "  Of  forty-three  distinctly  marked  cases  of  puerperal 
fever,  only  five  cases  of  the  whole  number  terminated  fatally. — 
The  thirty-eight  successful  cases  were  all  treated  by  copious  de- 
pletions of  one  kind  or  another,  and  in  twenty-nine  of  them  ca- 
lomel was  exhibited  in  doses  of  a  scruple,  or  half-drachm,  at  the 
beginning,  and  occasionally  repeated  in  the  course  of  the  dis- 
temper," p.  70. 

Dr.  Gordon,  whose  method  of  treating  puerperal  fever  consists 
in  large  bleeding  early  in  the  disease,  and  plentifully  purging, 
with  the  interposition  of  opiates,  informs  us  that  in  a  fair  trial 
of  his  method  in  fifty  cases,  only  five  died.  And  farther,  that 
all  the  five  died  before  he  had  discovered,  by  the  dissection  of 
his  fourth  case,  the  true  method  of  treating  the  disease;  and  that 
of  thirty  patients  treated  in  this  way,  not  one  died. 

It  is  evident,  from  all  that  can  be  collected  from  the  history  of 
puerperal  fever,  and  all  that  is  revealed  by  numerous  dissections, 
that  this  disease  consists  of  an  inflammation  of  some  one  portion 
of  the  peritoneum,  and  is  not  necessarily  confined  to  any  one 


PUERPEEAL    FEVER.  395 

viscus.1  But  this  inflammation  may  be  more  or  less  extensive ; 
it  may  be  more  or  less  violent;  and  it  may  run  its  course  with 
greater  or  less  rapidity,  as  its  type  may  chance  to  be.  But,  be 
it  in  extent  unlimited  or  confined ;  be  its  mildness  or  violence 
what  it  may;  be  its  course  rapid  or  slow,  it  nevertheless  consists 
of  inflammation  of  very  important  and  influential  structures  of 
the  human  body ;  and  requires  for  its  extinction  extensive  blood- 
lettings ;  sometimes  less  than  at  others,  but  always  liberal  purging, 
with  a  most  strict  antiphlogistic  regimen.  This  being  premised, 
we  shall  go  on  to  say  a  few  words  on  each  of  the  most  usual  re- 
medial agents,  as  employed  by  the  best  authorities,  and  most  ex- 
perienced practitioners  in  this  complaint. 

''"•"•    ^  '•>/;  . 

1.  Bleeding. 

This  remedy  was  first  extensively  employed  by  Dr.  Gordon 
for  the  cure  of  the  epidemic  puerperal  fever  which  appeared  at 
Aberdeen  in  the  year  1789,  and  continued  in  that  place,  with 
more  or  less  violence,  until  1792.  Soon  after  the  appearance  of 
this  disease,  he  discovered  that  early  and  large  bleeding,  with 
very  liberal  purging,  was  almost  sure  to  cure  this  complaint ;  but, 
that  the  first  remedy  could  not  be  advantageously  used  after  a 
certain  period  had  elapsed;  consequently,  its  efficacy  was  con- 
fined to  that  stage  of  the  disease  which  consists  in  an  active  in- 
flammation. If  bleeding  were  performed  after  this  active  stage 
had  passed,  it  was  either  ineffectual  or  injurious;  and  on  this  ac- 
count it  is  proper,  in  a  pathological,  as  well  as  in  a  therapeutical 
view,  that  we  should  ascertain  the  causes  which  render  a  diffe- 
rent plan  of  treatment  necessary,  as  the  disease  progresses ;  for 
this  purpose,  we  shall  divide  its  progress  into  three  stages,  each 
of  which  requires  a  certain  modification  of  treatment. 


a.  Stage  First. 

Dr.  Armstrong  makes  but  two  stages  of  puerperal  fever :  but 
we  are  of  opinion  that  a  third  is  essential  to  the  well-understand- 
ing of  the  disease.  We  are  certain  that  an  "intermediate  state,  or 
stage,  takes  place  in  puerperal  fever,  between  the  cessation  of 
the  inflammatory  stage  and  the  period  of  effusion;  and  may  be 
termed  the  "gangrenous  stage,"2  since  it  is  at  a  time  in  which 

1  See  pages  347-8. 

'  We  are  by  no  means  satisfied  with  the  term  employed  to  designate  the  state 
of  the  parts  at  this  period  of  the  disease:  we  use  it,  then,  with  a  full  conviction 
that  it  does  not  express  the  idea  which  we  would  wish  to  convey.  It  is  a  state  of 
a  part  which  approaches  death,  but  it  is  not  death;  because  parts  sometimes  re- 
cover from  it.  If  properly  managed,  that  is,  if  not  over-stimulated,  the  powers 


396  PUERPERAL   FEVER. 

the  vessels  have  not  absolutely  lost  their  life,  though  they  are  on 
the  very  verge  of  it.  It  is  at  this  period  that  hlood-letting  can 
do  no  good,  and  stimulants  will  destroy.  We  shall  have  occa- 
sion to  describe  the  stage  more  fully  hereafter. 

The  third  stage  is  that  at  which  effusion  takes  place,  and  at 
which  all  remedies  are,  as  a  general  rule,  unavailing. 

Dr.  Armstrong  describes  the  first  in  the  following  manner: — 

The  first  stage  is  variable  as  to  its  duration,1  sometimes  ter- 
minating in  a  little  more  than  twenty,  and  sometimes  continuing 
as  long  as  seventy  hours,  but  always  being  shorter  in  the  epi- 
demical than  in  the  peritonitic  fever."2 

It  will  be  seen,  at  once,  from  the  histories  already  given  of  this 
disease,  that  the  duration  of  this  stage  must  vary,  not  only  as  the 
disease  may  be  sporadic,  but  also  when  it  is  epidemic,  owing  to 
the  type  which  occult  causes  may  impose  upon  it.  In  a  practi- 
cal point  of  view,  therefore,  the  limit  of  this  stage  must  not  be 
rigidly  fixed  by  any  certain  number  of  hours.  This  stage,  strictly 
speaking,  consists  in  the  duration  of  the  active  state  of  inflamma- 
tion ;  and  this  will  vary,  as  just  observed,  from  the  contingencies 
of  season,  constitution,  age,  epidemical  influence,  &c.  In  the 
epidemic  described  by  Dr.  Leake,  this  stage  continued,  in  a  num- 
ber of  instances,  much  longer  than  the  greatest  limit  proposed 
by  Dr.  Armstrong;  for,  in  a  case  in  which  Dr.  Hunter  was  con- 
sulted, (case  IV.)  he  advised  bleeding  on  the  eighth  day.3 

It  would  be  of  great  importance,  in  the  treatment  of  this  dis- 
ease, were  there  certain,  or  infallible  signs,  which  would  charac- 
terize this  stage.  But,  unfortunately,  none  such  exist,  with  which 

of  the  system  may  be  such  as  to  recover  the  part  from  the  condition  in  which 
over  action  had  placed  it. 

1  It  must  be  borne  in  mind  that  Dr.  Armstrong  is  deducing  his  stages  from  a 
particular  epidemic;  and,  consequently,  that  the  duration  of  them  will  only  apply 
with  strictness  to  that  especial  puerperal  fever;  or,  rather, as  the  puerperal  fever 
exhibited  itself  at  that  time  and  place. 

4  By  the  "peritonitic  fever,"  we  presume  Dr.  A.  means  the  sporadic  puerperal 
fever:  as  every  body  seems  to  agree  that  the  latter  is  less  violent  in  its  symptoms, 
and  less  rapid  in  its  course,  than  when  this  disease  prevails  as  an  epidemic.  If 
this  be  not  his  meaning,  we  are  certainly  at  a  loss  for  it;  since  he  has  declared, 
in  the  initial  paragraph  of  his  preface,  that  "  under  the  common  term  puerperal 
fever,  are  comprehended  both  the  ordinary  peritoneal  inflammation,  and  the  'low 
malignant  fever  of  lying-in-women,'  as  these  are  considered  as  modifications  of 
the  same  disease."  Preface,  p.  1. 

1  We  may  also  refer  with  advantage,  as  regards  the  treatment  of  this  disease, 
to  Mr.  Hey's  twenty-seventh  case.  In  this  case,  he  bled  with  much  advantage, 
for  the  first  time,  on  the  fifth  day;  repeated  it  on  the  evening  of  that  day,  and  on 
the  day  following;  yet  Dr.  Armstrong  says  he  "  never  dared  to  recommend  blood- 
letting when  the  disease  had  continued  longer  than  thirty  hours,"  p.  76.  This 
declaration  of  Dr.  Armstrong  is  an  additional  proof  of  how  much  importance  it 
would  be  to  have  other  marks,  than  the  number  of  hours  which  may  elapse,  to 
judge  of  the  continuance,  or  cessation,  of  the  first  stage  of  puerperal  fever ;  for  it 
must  be  recollected,  as  before  observed,  that  the  fever  at  Leeds  was  rather  more 

malignant  than  that  of  Aberdeen. 

.<;  :>. •?;•'-••  7   .1  "•  a  r*  ,t   •*•&'          M       »  :  ;  •  ;  '..">i<*.-»     •  •  '••••'  ''I   "-'"  • 


PUERPERAL    FEVER.  397 

we  are  acquainted;  at  least,  none  "with  so  much  certainty  as  to 
remove  all  doubt.  Under  such  circumstances,  we  are  obliged  to 
rely  upon  symptoms;  though  pretty  strongly  marked,  yet  must 
not  be  looked  upon  as  unerring. 

The  pulse,  which,  in  most  other  inflammations,  so  faithfully 
directs  us,  here  deserts  us ;  at  least,  we  cannot  judge  of  it  in 
puerperal  fever,  as  in  pleurisy,  or  common  fevers ;  as  this  disease 
imposes  a  character  upon  it,  which,  with  our  present  notions, 
would  greatly  mislead  us. 

Mr.  Hey  says,  "  The  state  of  the  pulse  affords  little  information, 
either  as  to  the  propriety  of  bleeding,  or  the  quantity  of  blood 
proper  to  be  taken  away ;  and  if  we  are  deterred  either  by  the 
apparent  weakness  of  the  patient,  by  the  feebleness  and  frequency 
of  the  pulse,  or  by  any  other  symptom,  from  bleeding  copiously, 
we  shall  generally  fail  to  cure  the  disease,"  p.  161. 

This  statement  clearly  shows  that  neither  Mr.  Hey,  nor  those 
who  have  preceded  him,  were  in  possession  of  any  sign  by  which 
they  could,  with  absolute  certainty,  determine  the  existence  or 
termination  of  the  first  stage  of  this  disease.  The  pulse,  the 
common,  and,  generally,  the  certain  guide  in  other  febrile  affec- 
tions, we  are  warned  not  to  rely  upon,  for  it  will  deceive  us ;  on 
what,  then,  are  we  to  rely?  Mr.  Hey  says,  "If  the  disease  is 
clearly  ascertained,  no  other  consideration  is  of  much  import- 
ance," p.  161.  This  assertion  is  not  made  with  Mr.  Key's  usual 
caution  and  discrimination ;  for  puerperal  fever  is  still  puerperal 
fever  throughout  its  stages ;  yet  Mr.  Hey  is  particular,  in  other 
places,  that  the  treatment  of  one  stage  should  not  be  pursued  in 
another. 

We  are  willing  to  admit  that  "the  state  of  the  pulse  affords 
little  information,"  in  our  present  state  of  knowledge  of  that 
function;  but  we  cannot  be  persuaded  but  that  every  active 
morbid  condition  of  the  system,  has  a  modifying  influence  upon 
the  heart  and  arteries;  and  which  could  be  detected,  were  our 
powers  of  discrimination  equal  to  the  necessity  and  usefulness  of 
such  a  knowledge.  In  the  disease  in  question,  a  disease  of  such 
deadly  tendency,  and  rapid  termination,  the  importance  of  the 
structure  which  is  its  seat,  the  decided  control  it  has  over  some 
of  the  powers  or  actions  of  the  heart  and  arteries,  would  lead  us 
almost  necessarily  to  conclude,  that  the  mode  of  action  of  these 
important  viscera  is  peculiar,  and  every  way  highly  characteristic 
in  puerperal  fever,  did  we  but  possess  the  tact  to  detect  it. 

We  would,  therefore,  earnestly  caution  the  practitioner  against 
being  betrayed  into  an  indifference  about  the  state  and  character 
of  the  pulse,  that  the  assertion  of  Mr.  Hey  would  almost  certainly 
lead  to;  and,  on  the  contrary,  would  decidedly  recommend  to 
him  the  study  of  the  pulse,  and  other  signs  in  puerperal  fever, 
with  a  hope  that  the  secret  characters  of  peritoneal  inflammation, 


398  PUERPERAL   FEVER. 

in  its  various  grades,  may  be  detected ;  and  thus  confer  upon 
society  a  never-ending  benefit. 

For,  that  there  are  characters  of  pulse  in  puerperal  fever,  (we 
must  repeat,)  we  are  persuaded;  and,  that  they  are  susceptible 
of  development,  we  as  confidently  believe;  but  to  detect  them 
with  a  certainty  that  may  be  useful,  will  perhaps  require  much 
experience  and  patient  application,  together  with  a  most  nice 
and  discriminating  touch.  This  faculty,  (the  touch,)  like  all  our 
other  faculties,  may  be  much  improved  by  well-directed  disci- 
pline; its  powers  should,  therefore,  be  carefully  cultivated  by 
the  physician  who  is  desirous  of  extending  the  benefits  of  his 
profession  to  his  fellow  creatures.  For,  it  is  but  by  repeated 
trials  and  careful  observation,  that  the  faculty  of  discrimination 
can  exist  in  an  accurate  or  an  exalted  degree ;  and  when  it  does 
not  exist  in  such  a  degree,  it  cannot  serve  the  purposes  so  much 
desired. 

Farther,  the  touch,  like  the  other  faculties,  exists  in  various 
degrees  of  perfection,  as  an  original  condition ;  consequently,  it 
is  not,  in  every  instance,  susceptible  of  the  same  cultivation :  but 
in  all  it  is  capable  of  much  improvement ;  or  at  least  with  very 
few  exceptions.  We  would,  therefore,  earnestly  recommend  the 
attempt.  As  illustrative  of  this  point,  and  some  others  connected 
with  the  pulse,  we  think  we  cannot  do  better  than  to  employ  the 
language  of  Mr.  Hunter  upon  this  subject. 

"The  pulse  is  often  as  strong  a  sign  of  the  state  of  the  con- 
stitution as  any  other  action  that  takes  place  in  it,  though  it  is 
not  so  always ;  but,  as  the  pulse  has  but  one  circumstance  at- 
tending it  that  we  can  really  measure,  all  the  others  being  refer- 
rible  to  the  sensation  or  feeling  of  the  person  who  is  the  judge 
of  it,  the  true  state  of  the  pulse  is  not  easily  ascertained.  The 
knowledge  of  the  soft,  the  hard,  and  the  thrill,  are  such  as  can 
only  be  acquired  with  accuracy  by  the  habit  of  feeling  pulses  in 
these  different  states,  and,  by  many,  is  not  to  be  attained;  for 
simple  sensation  in  the  minds  of  any  two  men  is  seldom  alike. 

"The  late  Dr.  Hunter  was  a  striking  instance  of  this,  for, 
though  he  was  extremely  accurate  in  most  things,  he  could  never 
feel  that  nice  distinction  in  the  pulse  that  many  others  did,  and 
was  ready  to  suspect  more  nicety  of  discrimination  than  can  really 
be  found.  Frequency  of  pulsation  in  a  given  time  is  measura- 
ble by  instrument;  smartness  or  quickness  in  the  stroke,  with  a 
pause,  is  measurable  by  the  touch ;  but  the  nicer  peculiarities  in 
the  pulse  are  only  sensations  in  the  mind.  I  think  I  have  been 
certain  of  the  pulse  having  a  disagreeable  jar  in  it,  when  others 
did  not  perceive  it ;  when  they  were  only  sensible  of  its  frequency 
and  strength:  and  it  is,  perhaps,  this  jar  that  is  the  specific  dis- 
tinction between  constitutional  disease  or  irritation  and  health. 
Frequency  of  pulsation  may  often  arise  from  stimulus,  but  the 


PUERPERAL    FEVER.  399 

stroke  will  then  be  soft;  yet  softness  is  not  be  depended  on  as 
a  mark  of  health :  it  is  often  a  sign  of  dissolution ;  but  then  there 
must  be  other  attending  symptoms."  Treatise  on  the  Blood, 
Am.  ed.  p.  265. 

From  what  has  been  said,  it  is  evident  that  the  touch  is  more 
or  less  perfect  in  its  condition,  as  an  original  sense;  and  that  it  is 
capable  of  much  improvement  in  its  powers  of  discrimination; 
and  from  what  follows,  it  will  be  found  there  is  much  to  learn  of 
the  various  conditions  of  the  pulse,  as.  depending  upon  the  nature, 
seat,  and  force  of  disease ;  and  that  the  opinion,  that  the  state 
of  the  heart  and  arteries,  if  duly  distinguished,  may  lead  to  the 
knowledge  of  the  condition  or  state  of  morbid  action,  in  any 
particular  structure  of  the  body,  is  not  altogether  chimerical. 
To  prove  this,  we  shall  continue  our  quotation  from  that  high 
authority,  Mr.  Hunter. 

"In  the  consideration  of  the  peculiarities  of  the  pulse,  it  is  always 
necessary  to  observe,  that  there  are  two  powers  always  acting 
to  produce  them,  the  heart  and  the  arteries;  that  one  part  of  the 
pulse  belongs  to  the  heart  alone,  another  to  the  arteries  alone,  and 
a  third  is  a  compound  of  both.  But  the  action  of  the  heart  and 
arteries  do  not  always  correspond ;  the  heart  may  be  in  a  state 
of  irritation,  and  act  quickly  in  its  systole,  while  the  arteries  may 
be  acting  slowly ;  for  the  heart  must  be  considered  as  local,  while 
the  vessels  must  be  considered  universal,  or  even  constitutional. 
The  stroke,  which  is  the  pulse,  with  the  number  of  them  that  are 
made  in  a  given  time,  whence  the  pulse  is  commonly  called  quick 
or  slow,  their  regularity  or  irregularity,  as  to  time,  and  the  quick- 
ness of  the  stroke  itself,  belongs  to  the  heart.  The  quickness  of 
the  heart's  action  often  takes  place,  though  the  pulsations  are  not 
frequent,  which  gives  a  kind  of  rest  or  halt  to  the  artery,  or  pulse, 
especially  if  the  pulse  be  not  frequent.  The  hardness,  the  vibra- 
tory thrill,  the  slowness  of  the  systole,  with  the  fulness  and  small- 
ness  of  the  pulse,  belong  to  the  arteries.  As  the  pulse  arises  from 
the  solids,  or  the  machine,  its  state  will  be  of  course  according  to 
the  nature  of  the  machine  at  the  time;  and  is,  therefore,  capable 
of  being,  in  either  of  these  states,  natural  and  diseased. 

"  In  most  diseases  of  the  constitution,  whether  originating  from 
it,  or  arising  in  consequence  of  diseases  of  parts,  where  the  con- 
stitution becomes  affected  by  sympathy,  the  pulse  is  altered  from 
a  natural  to  a  diseased  state,  the  degree  of  which  will  be  regu- 
lated by  those  affections.  This  alteration  is  commonly  so  constant, 
and  so  regularly  of  the  nature  of  the  disease,  that  it  is  one  of  the 
first  modes  of  intelligence  we  have  recourse  to,  in  our  inquiries 
into  its  nature:  but  alone  it  is  not  always  a  certain  guide." 

"The  varieties  which  the  pulse  admits  of  are  several.  It  is 
increased  in  its  number  of  strokes,  or  it  is  diminished.  It  is  re- 


400  PUERPERAL   FEVER. 

gular,  or  it  is  irregular,  as  to  time  in  its  stroke;  it  is  quick  in 
its  stroke,  or  diastole,  and  slow  in  its  systole.  It  is  hard  in  its 
diastole,  and  it  vibrates  in  its  systole. 

"In  most  cases,  probably  where  the  constitution  is  in  a  state 
of  irritation,  the  pulse  will  be  quick  and  frequent  in  its  number 
of  strokes  in  a  given  time,  and  the  artery  will  become  hard,  from 
a  constant  or  spasmodic  contraction  of  its  muscular  coats,  so  as 
to  give  the  feel  of  hardness  to  the  touch ;  besides  which,  the  dias- 
tole of  the  artery  is  not  regularly  uniform  and  smooth,  but  pro- 
ceeds by  a  vast  number  of  stops,  and  interruptions,  which  are  so 
quick  as  to  give  the  feel  of  vibration,  or  what  we  could  express 
a  thrill."  Ib. 

These  quotations  are  sufficient  to  prove  that  the  condition  of 
the  artery  in  disease,  as  regards  its  volume,  its  firmness,  its 
softness,  its  frequency,  or  its  peculiarities  of  action,  very  much 
depends  upon  the  nature  of  the  disease  which  imposes  the  altera- 
tion; and  that  the  diseased  action  itself  will  be  influenced  by 
the  particular  structure  or  structures  which  are  the  seat  of  it. 
If  this  be  true,  and  we  can  see  no  reasonable  doubt  of  it,  it  seems 
to  follow,  that  the  peritoneum,  in  a  state  of  inflammation,  will 
give  to  the  heart  and  arteries  a  character  of  action  which  exclu- 
sively belongs  to  that  condition  of  this  membrane ;  and  that  the 
actions  of  the  artery  will  of  course  vary  with  the  varying  con- 
dition of  the  part  or  parts  inflamed. 

As  regards  ourselves,  we  profess  to  have  much  reliance  upon 
the  pulse  in  all  acute  affections  of  the  body ;  and  almost  always 
make  it  the  guide  of  our  prescriptions ;  yet  we  confess  we  have 
less  dependence  upon  it  in  puerperal  fever,  than  in  any  other 
disease  with  which  we  are  acquainted.  Not,  perhaps,  because  it 
is  unfaithful  in  its  reports  of  the  condition  of  the  system,  but  be- 
cause, we  fear,  we  do  not  exactly  understand  them.  The  study 
of  the  pulse,  therefore,  in  puerperal  fever  is  almost  a  new  one ; 
and  we  most  earnestly  recommend  it  to  those  who  may  almost 
Constantly  have  the  charge  of  females,  with  a  firm  conviction 
that  they  will  be  amply  repaid  for  their  labours.1  But  to  return. 
We  would  ask,  what  is  the  evidence  that  the  first  stage  has 
run  its  course?  This  is  an  important  question;  and  one,  from 
our  present  data,  that  cannot,  we  fear,  be  answered  satisfactorily. 
Hitherto  this  condition  of  the  disease  has  been  inferred,  rather 
than  ascertained.  It  has  been  inferred,  from  the  little  advantage 
in  some  cases,  and  the  marked  injury  in  others,  of  blood-letting  ; 
and  this  is  probably  the  amount  of  information  upon  the  subject; 

1  Mr.  Travers  says  that  the  pulse  of  real  fever  does  not  exceed  a  certain  limit, 
and  that  consists  with  a  property  of  distinctness.  When  it  is  innumerable,  and 
from  that  cause  indistinct,  it  ceases  to  be  fever ;  it  is  a  powerless  automatic  ac- 
tion, and  has  neither  the  characteristics  of  heat  of  surface  nor  obstruction  of  the 
general  secretory  system. 


PUERPERAL    FEVER.  401 

hence,  perhaps,  the  rule  for  withholding  the  lancet  in  certain  epi- 
demical puerperal  fevers,  being  regulated  by  hours ;  for  it  would 
seem,  that  in  each  individual  epidemic  of  this  nature,  there  is  a 
period,  cseteris  paribus,  at  which  the  first  stage  runs  its  course, 
and  this  period  has  been  signified  by  hours,  because,  when  the 
disease  had  continued  beyond  this  time,  and  blood-letting  resorted 
to,  it  either  proved  unavailing  or  mischievous ;  consequently,  the 
first  stage  was  supposed  to  be  past. 

Thus,  Dr.  Gordon  would  not  promise  success  from  bleeding, 
if  the  disease  had  continued  from  twelve  to  twenty  hours ;  be- 
cause this  was  probably  the  average  period  for  the  first  stage, 
in  the  Aberdeen  epidemic;  and  Dr.  Armstrong  says  he  has 
"  never  dared  to  recommend  it  when  the  disease  had  continued 
longer  than  thirty  hours,"  p.  76 ;  because  in  the  Sunderland  epi- 
demic, this  may  have  been  the  period  for  the  change  from  the 
first  to  the  second  stage,  &c. 

It  is  true  that  Dr.  Armstrong  has  attempted  the  character  of 
the  first  stage,  by  detailing  certain  symptoms,  and  has  perhaps 
succeeded  better  than  any  one  else  in  defining  and  ascertaining 
its  bounds ;  nevertheless,  he  must  not  be  considered  as  being  al- 
together successful.  It  is,  however,  a  praiseworthy  attempt; 
and  he  is  entitled  to  the  thanks  of  the  profession,  for  the  lucid 
manner  in  which  he  has  treated  the  subject. 

"In  the  first  stage,"  he  says,  "after  the  rigours  have  ceased, 
the  pulse  is  hardly  ever  less  than  one  hundred  and  twenty,  and 
sometimes,  though,  as  far  as  I  have  observed,  very  seldom,  as 
high  as  one  hundred  and  forty  in  a  minute :  the  blood  does  not 
seem  to  flow  in  a  soft,  easy,  and  natural  current,  but  comes 
against  the  finger  with  a  kind  of  vibratory  motion,  and  more 
than  ordinary  pressure  is  commonly  required  to  stop  its  course 
along  the  artery,  which  feels  rather  hard  and  tense.  The  skin 
is  dry,  and  hotter  than  natural;  the  patient  complains  of  great 
pain  and  soreness  of  the  abdomen,  breathes  nearly  forty  times 
in  the  minute,  vomits  mucus  and  bile,  is  generally  bound  in  the 
belly,  has  a  white,  dry  tongue,  considerable  thirst,  and  labours 
under  all  the  restlessness  and  irritation  of  fever,"  p.  59. 

This  description  looks  as  if  it  were  every  way  competent  to 
the  purposes  for  which  it  is  designed;  yet  there  is  not  a  symp- 
tom, well  defined  as  it  seems  to  be,  that  may  not  accompany  the 
second  stage,  if  we  except,  perhaps,  "rigour,"  which  must  be 
looked  upon,  when  it  takes  place,  as  the  initial  symptom  of  the 
constitutional  affection,  and  is  of  short  duration.1 

The  pulse  is  said  to  be  from  one  hundred  and  twenty  to  one 

'Dr.  Armstrong,  however,  includes  chills  in  his  second  stage:  to  have  made 
these  characteristics,  he  should  have  added,  that  these  chills  are  not  followed  in> 
mediately  by  a  sense  of  increased  heat. 

26 


402  PUERPERAL    FEVER. 

hundred  and  forty  strokes  in  a  minute ;  so  it  happens  in  some 
instances  of  the  second  stage ;  and  Dr.  Gordon  says  he  has  bled 
in  some  cases  with  good  effect,  when  the  pulse  has  been  one  hun- 
dred and  sixty ;  therefore,  if  the  bleeding  with  advantage  be  the 
proof  of  the  presence  of  the  first  stage,  the  second  cannot  be 
characterized  by  a  pulse  of  one  hundred  and  forty;  since  one 
hundred  and  sixty  have  been  witnessed  during  the  first  stage. 
In  Mr.  Key's  case,  (3d,)  the  pulse  is  recorded  to  be  at  between 
one  hundred  and  thirty  and  one  hundred  and  forty  on  the  fifth 
day,  and  at  a  time  when  all  hope  was  abandoned;  and  it  was 
but  one  hundred  and  forty-four,  (a  number  considerably  within 
the  range  at  which  Dr.  Gordon  says  he  has  bled  profitably,)  a 
short  time  before  death.  Mr.  Hey's  case,  (5th,)  terminated  fa- 
tally in  thirty-five  hours;  and  its  commencement  "was  accompa- 
nied with  a  full,  strong  pulse."  In  his  sixth  case,  the  pulse  was 
one  hundred  and  thirty  in  the  last  stage.  We  might  furnish  many 
more  cases  of  similar  import ;  but  these  are  sufficient  to  prove  that 
the  number  of  pulsations  of  the  artery  in  a  given  time  will  neither 
mark  the  first,  nor  characterize  the  second,  stage  of  this  disease. 

We  should  place  much  more  reliance  on  that  peculiarity  of 
the  pulse  which  Dr.  Armstrong  describes,  "where  the  blood  does 
not  seem  to  flow  in  a  soft,  easy,  natural  current,"  &c.;  if  it  were 
found  to  be  a  constant  symptom,  and  to  be  detected  with  cer- 
tainty by  even  close  attention,  as  it  seems  to  countenance  the 
opinion  hinted  above,  that  the  inflammatory  stage  most  probably 
is  accompanied  by  a  distinctive  arterial  action,  however  evanes- 
cent it  may  be  in  duration,  or  however  difficult  of  detection. 

The  state  of  the  skin  is  very  much  less  characteristic  than  even 
the  pulse ;  for  in  the  first  stage  it  is  frequently  moist,  nay,  wet ; 
and  in  the  second,  it  is  both  hot  and  dry.  The  pain  and  sore- 
ness of  the  abdomen  often  continue  through  the  whole  disease ; 
and  though  never  absent  from  the  first  stage,  it  is  nevertheless 
constantly  present  in  the  second.  The  breathing  is  not  more 
decisive ;  vomiting  is  less  frequent  in  the  first  than  in  the  se- 
cond stage.  The  tongue  affords  no  criterion ;  it  remains  some- 
times as  described  above,  until  death  closes  the  scene.  Thirst  is 
sometimes  insatiable  in  the  last  stage;  and  the  restlessness  and 
irritation  from  fever  attend  sometimes  to  the  last  moment. 

We  should,  however^  place  some  reliance  upon  the  character 
of  the  pain  and  soreness,  mentioned  as  belonging  to  the  first 
stage :  it  is  generally  of  an  acute,  pungent  kind ;  more  easily 
excited  by  pressure  at  one  portion  of  the  abdomen  than  another ; 
and  very  frequently  confined  to  the  hypogastrium :  there  may 
be  some  swelling  from  the  very  commencement,  which  is  sure  to 
augment  as  the  disease  gains  ground,  giving  to  the  hand  the  sen- 
sation of  more  or  less  solidity;  but  the  distention  is  never  exces- 
sive during  this  stage ;  is  obedient  to  the  influence  of  remedies, 


PUERPERAL    FEVER.  403 

by  diminishing  in  size  and  sensibility;  provided,  the  remedies 
exert  a  control  over  the  disease  generally.  The  patient  is  some- 
times disposed,  and  sometimes  does,  turn  upon  her  side;  though 
obviously  inclined  to  maintain  her  position,  for  the  most  part, 
upon  her  back ;  because  the  abdominal  muscles,  by  being  relaxed, 
moderate  pain. 

It  would  appear,  then,  that  the  first  or  inflammatory  stage  of 
puerperal  fever,  the  stage  in  which  bleeding  has  been  so  emi- 
nently successful,  has  no  discovered  character  by  which  it  can  be 
distinguished  from  the  second,  in  which  this  operation  is  for- 
bidden after  the  lapse  of  a  few  hours.  This  circumstance  we 
must  regard  as  unfortunate,  but  perhaps  not  without  remedy :  for 
we  must  still  insist  that  there  cannot  be  such  a  departure  from 
the  usual  economy  of  the  system,  as  to  make  puerperal  fever  the 
only  exception.  We  must  be  borne  with,  therefore,  if  we  still 
persist  in  recommending  to  physicians  a  more  exclusive  devotion 
to  and  study  of  the  several  stages  of  this  disease,  that  their  now 
hidden  characters  may  be  developed. 

The  rules  which  are  to  govern  the  loss  of  blood  in  this  com- 
plaint are  therefore  necessarily  reduced  to  rather  uncertain 
and  narrow  limits;  and  are  more  dependent  upon  contingencies 
than  fixed  principles.  These  rules  are  comprised  in  the  follow- 
ing directions : — 

1.  Bleed  as  early  in  the  disease  as  possible.     But, 

2.  Bleed,  at  that  time,  as  much  as  the  system  will  well  bear. 

3.  Repeat,  pro  re  nata. 

1st.  Every  practitioner  is  aware  of  the  difficulty  which  almost 
constantly  attends  the  execution  of  the  first  direction :  this  arises 
from  several  causes;  but  none  of  which  are  absolutely  insur- 
mountable. First;  to  the  initial  symptoms  of  the  disease  being 
frequently  mistaken  for  the  common  occurrences  of  child-bed — 
if  chill  attend,  as  is  most  common,  or  if  fever  ensue  without  it, 
it  is  commonly  attributed  to  the  "coming  of  the  milk,"  or  that 
ephemeral  called  the  "weed;"  or  to  some  slight  exposure,  or 
unforeseen  negligence.  Second,  to  the  desire  on  the  part  of  the 
nurse  to  be  thought  competent  to  any  little  indisposition  incident 
to  this  period  of  child-bed.  Third,  to  the  consequence  of  this 
belief  of  the  nurse;  losing  thereby  much  time  in  witnessing  the 
effects  of  her  own  remedies.  Fourth,  to  the  fear  of  censure 
attaching  to  the  nurse  for  any  indisposition  by  which  her  patient 
may  be  attacked;  therefore  withholding  early  information. 
Fifth ;  to  an  ignorance  of  the  nature  and  fatal  tendency  of  the 
disease.  Sixth,  if  pain  commence  early,  to  its  being  mistaken 
for  after-pains. 

For  the  reasons  just  assigned,  it  will,  in  very  many  cases,  be 
out  of  the  physician's  power  to  treat  the  disease  as  early,  or  as 
vigorously,  as  its  ferocity  demands ;  therefore  he  should  prevent, 
as  far  as  possible,  the  operation  of  the  above  causes,  whenever 


404  PUERPERAL    FEVER. 

the  necessity  may  exist,  by  following  the  plan  adopted  by  Mr. 
Hey,  during  the  prevalence  of  the  puerperal  fever  at  Leeds.  He 
requested  to  be  sent  for  "without  delay,  on  the  accession  of 
shivering  or  unusual  pain."  But  he  adds,  "Notwithstanding 
my  urgent  request,  I  was  seldom  called  until  some  hours  after 
the  attack,"  p.  76.  This  declaration  diminishes  our  hopes  of 
early  applications,  it  is  true ;  but  the  plan  should  be  tried,  as  it 
is  the  only  one  we  can  adopt  for  the  end  proposed. 

We  have  already  mentioned  the  latest  periods,  in  the  opinions 
of  several  of  the  best  authorities  on  this  subject,  at  which  it 
would  be  useful  or  proper  to  bleed ;  we  also  attempted  to  show 
that  these  directions  were  founded  upon  experience,  or  rather 
experiment,  upon  different  occasions ;  that,  though  there  were 
discrepancies  in  appearance  in  these  statements,  yet  there  were 
none  in  reality;  as  the  conclusions  were  drawn  from  individual 
experience,  in  each  of  the  epidemics  of  which  they  gave  the 
histories,  and,  consequently,  that  neither  the  short  periods  of 
Armstrong  and  Gordon,  nor  the  more  extended  ones  of  Denman 
and  Hey,  should  be  taken  for  absolute  guides. 

Therefore,  in  every  instance  of  puerperal  fever,  especially  in 
epidemic,  as  well  as  in  sporadic  cases,  there  may  be  a  difference 
of  period  at  which  it  might  be  proper  to  bleed ;  and  that  this 
period  should  be  discovered  as  early  as  possible,  and  its  limits 
ascertained  with  as  much  precision  as  it  is  susceptible  of.  For, 
by  this  means,  we  may  extend  the  benefits  of  this  operation  be- 
yond what  might  at  first  be  expected,  as  well  as  be  prevented 
from  doing  mischief  by  it,  if  too  lately  employed. 

As  regards,  then,  the  period  after  the  attack  at  which  we  are 
to  draw  blood,  it  is  a  concurrent  opinion,  the  earlier,  most  de- 
cidedly the  better:  as  respects  the  one  at  which  this  would  no 
longer  be  useful,  we  have  but  very  uncertain  marks ;  therefore, 
much  must  be  left  to  the  experience  and  judgment  of  the  practi- 
tioner who  may  have  the  care  of  the  case. 

2.  Having  ascertained  the  propriety  of  blood-letting  in  the 
early  period  of  the  disease,  the  questions  next  in  importance  are 
first,  what  quantity  must  be  drawn ;  and  secondly,  must  it  be 
repeated,  and  when,  or  under  what  circumstances  ? 

All  the  writers  who  have  treated  this  disease  with  adequate 
boldness,  prescribe  the  loss  of  a  given  quantity  of  blood;  thus, 
Gordon,  Hey,  and  Armstrong,  limit  it  from  twenty  to  thirty 
ounces ;  believing  that  less  will  not  answer,  and  more  is  not  gene- 
rally required.1  In  this  country  we  are  not  in  the  habit  of  regu- 

1  Dr.  Armstrong  says, "  The  quantity  of  blood  drawn  at  once  in  puerperal  fever 
should  seldom  be  less  than  twenty-four,  and,  perhaps,  never  more  than  thirty 
ounces,"  p.  76. 

Dr.  Gordon  says,  "  I  have  limited  the  quantity  of  blood  necessary  to  be  taken 
away,  and  fixed  the  time  when  taking  away  that  quantity  will  cure.  Thus,  1 
found  that  twenty-four  ounces  of  blood,  taken  away  at  one  bleeding,  within  six  or 


PUERPERAL   FEVER.  405 

lating  our  bleedings  by  ounces ;  in  severe  illnesses  we  almost  alto- 
gether regulate  the  quantity  by  its.  effects ;  and  we  are  disposed 
to  believe  this  to  be  the  safer  and  the  more  efficient  plan.'  For 
it  is  not  to  be  supposed  that  every  constitution  will  be  affected 
precisely  alike ;  nor  that  the  disease,  in  every  constitution,  will 
yield  to  exactly  the  same  force  of  remedies.  In  one  instance, 
perhaps,  a  less  quantity  than  twenty  or  thirty  ounces  might  be 
sufficient,  while  another  might  require  a  much  larger  quantity ; 
therefore,  in  the  one  more  blood  may  be  drawn  than  is  absolutely 
necessary,  (though  we  confess  it  to  be  erring  on  the  safer  side,) 
and  in  the  other,  which  is  much  more  material,  an  inadequate 
quantity  is  too  confidently  relied  upon. 

As  regards  our  own  practice,  in  such  cases,  we  have  always 
abstracted  as  much  as  the  system  would  well  bear ;  that  is,  until 
the  pulse  was  changed,  pain  abated,  fever  diminished,  and  there 
was  a  disposition  to  syncope.  These  alterations  would  take  place 
sometimes  from  the  loss  of  a  smaller,  and  sometimes  a  larger 
quantity  of  blood:  but  until  these  did  take  place,  we  could  not 
flatter  ourselves  that  we  had  strangled,  or,  perhaps,  even  weak- 
ened, the  disease ;  but  this  we  always  attempted,  did  it  require 
only  twenty  ounces,  or  did  it  demand  forty. 

In  constitutions  wont  to  faint  from  the  loss  of  a  little  blood, 
we  cannot  always  get  at  one  bleeding  the  necessary  quantity ; 
the  operation  is,  therefore,  to  be  repeated  so  soon  as  the  system 
reacts  with  decided  force;  unless  all  the  expected  relief  be  ob- 
tained by  that  which  has  already  been  done.  We  do  not  wait 
for  the  lapse  of  any  certain  number  of  hours  to  repeat  the  bleed- 
ing; for  we  are  persuaded,  in  doing  so,  we  permit  the  disease  to 
gain  ground ;  we  should,  therefore,  draw  it  as  quickly  as  the  state 
of  reaction  will  permit,  if  the  symptoms  continue. 

Dr.  Armstrong  says,  "  If  the  patient,  as  sometimes  happens, 
faint  under  the  first  operation,  when  only  four  or  five  ounces  of 
blood  have  been  taken  away,  unless  there  be  an  abatement  of  all 
the  urgent  symptoms,  another  vein  ought  to  be  opened,  after  the 
lapse  of  one  or  two  hours,  and  about  twenty  ounces  taken  in  a 
full  stream,"  p.  78. 

We  would  ask,  why  we  should  "wait  an  hour  or  two"  in  this 
case,  before  we  repeat  the  bleeding  ?  The  answer  may  be,  because 
there  is  "an  abatement  of  all  the  urgent  symptoms:"  this,  we 
admit,  will  almost  certainly  be  the  case  during  the  temporary 
prostration  of  the  system,  but  no  longer,  in  some  instances ;  as 

eight  hours  after  the  attack  of  the  disease,  together  with  a  single  purgative,  never 
failed,  at  once,  to  cure  the  puerperal  fever,"  p.  84.  On  this,  Mr.  Hey  makes  the 
following  remarks :  "  Though  I  have  found  great  advantage  from  the  rules  laid 
down  by  Dr.  Gordon,  yet  it  is  incumbent  upon  me  to  say,  that  they  were  not  al- 
ways infallible,  either  as  to  the  quantity  of  blood  which  was  necessary  for  the 
cure,  or  the  time  within  which  it  should  be  taken,"  p.  156. 


40G  PUERPERAL  FEVER. 

there  is  commonly  a  renewal  of  all  the  more  violent  symptoms 
the  moment  reaction  is  re-established ;  therefore  the  period  of  re- 
action should  be  the  rule.  For,  in  some  remarkable  cases,  this 
state  of  fainting  may  continue  beyond  the  period  prescribed,  when 
it  would  be  highly  injudicious  to  repeat  the  bleeding;  while  in 
others,  reaction  may  take  place  in  a  few  minutes  :  in  such  a  case, 
it  would  be  losing  precious  time  to  wait  "an  hour  or  two"  for 
the  second  bleeding ;  and  in  the  other  we  might  draw  blood  at 
an  improper  moment.  Besides,  the  rule  we  have  laid  down  is 
void  of  all  ambiguity. 

3d.  The  necessity  for  farther  bleeding  must  be  determined  by 
the  existence  and  urgency,  of  the  original  symptoms;  such  as 
fever,  with  accelerated  pulse ;  vomiting ;  heat ;  and  pain  without 
much  swelling.  Indeed,  as  far  as  our  experience  will  warrant 
the  deduction,  the  state  of  the  abdominal  swelling,  and  the  de- 
gree of  acute  pain  without  much  distention  of  the  abdomen,  are 
much  more  certain  marks  of  the  continuance  of  active  inflamma- 
tion, or  the  first  stage,  than  any  others  we  are  acquainted  with  ; 
and  that  it  is  much  safer  to  rely  upon  them  than  upon  the  pulse ; 
because  the  various  conditions  of  the  latter  are  but  very  ill  un- 
derstood. So  far  these  circumstances  have  directed  us,  and,  we 
may  add,  successfully.  We  have  already  declared,  however,  that 
our  experience  has  not  been  extensive.1 

Our  rule  hitherto  has  been,  when  the  first  bleeding,  which,  as 
we  have  observed,  we  always  make  a  very  liberal  one  if  called 
to  the  disease  early,  does  not  abate  the  severity  of  the  symptoms 
in  three  or  four  hours,  to  repeat  it  without  hesitation :  but  not  to 
the  extent  of  the  first,  as  evidences  of  its  influence  manifest  them- 
selves before  an  equal  quantity  is  drawn.  Nor  do  we  limit  it  to 
this  single  repetition ;  for,  if  the  disease  be  not  abated  in  severity, 
we  know  of  no  other  general  remedy  that  has  the  slightest  con- 
trol over  it.  And  we  are  persuaded  that  the  farther  abstraction 
of  blood  is  necessary,  either  from  the  arm,  or  locally,  by  leeches. 

It  is,  however,  to  be  understood,  that  purging  is  to  be  imme- 
diately commenced  after  the  first  bleeding,  and  persevered  in,  as 
we  shall  direct  more  particularly  presently. 

Mr.  Key's  rule  is,  "If  the  pain  and  soreness  of  the  abdomen 
are  not  removed,  or  very  materially  alleviated,  in  nix  hours,  the 
bleeding  ought  to  be  repeated ;  nor  should  a  considerable  degree 
of  faintness,  or  even  deliquium,  make  us  suppose  that  farther 
bleeding  is  either  unsafe  or  unnecessary.  In  short,  I  know  not, 
from  any  experience  of  my  own,  that  scarcely  any  other  limit 
should  be  put  to  the  quantity  of  blood,  than  the  removal,  or  con- 

1  The  reader  will  readily  understand  the  reason  of  this,  by  what  has  already 
been  said  of  the  rare  appearance  of  this  disease  in  this  city. 


PUERPERAL   FEVER.  407 

siderable  diminution  of  the  pain ;  provided  all  that  is  requisite  be 
drawn  within  twelve  hours  of  the  first  evacuation,"  p.  161. 

We  think  the  plan  just  mentioned  a  very  good  one ;  though 
we  should  prefer  making  the  interval  rather  shorter,  provided 
the  symptoms  continue  to  be  urgent;  for  we  are  well  persuaded 
nothing  is  gained  by  delay,  unless  there  be  an  abatement  of  the 
symptoms ;  and  we  believe  that  this  should  be  the  rule  upon  most 
occasions.  The  temporary  amendment  procured  by  the  bleeding 
must  not  be  mistaken  for  such  a  reduction  of  the  disease  as  to 
render  the  repetition  unnecessary ;  for,  if  there  be  a  renewal  of 
all  the  distressing  symptoms,  the  disease  must  be  considered  as 
being  still  in  full  force,  though  the  rapidity  of  its  march  may  be 
a  little  abated  by  what  has  already  been  done. 

We  must  object  to  an  entire  conformity  with  Mr.  Hey's  pro- 
viso, namely,  that  "all  the  blood  designed  to  be  drawn  should  be 
within  twelve  hours  of  the  first  evacuation ;  "  for  we  are  persuaded 
we  have  seen  bleeding  do  much  good  after  a  much  longer  period, 
where  the  force  of  the  disease  has  been  abated  by  the  preceding 
evacuations.  For  it  is  but  reasonable  to  suppose,  even  in  the 
puerperal  fever,  which  runs  its  course  rapidly,  that  the  tendency 
to  disorganization  will  be  diminished  by  proper  remedies;  there- 
fore, a  greater  latitude,  as  regards  hours,  we  think,  may  be  per- 
mitted, provided  the  symptoms  do  not  display  the  same  intensity, 
yet  evidently  remain  unsubdued. 

Dr.  Armstrong  discovers  still  greater  apprehension  of  repeating 
the  bleeding.  He  says,  "  The  quantity  of  blood  drawn  at  once  in 
puerperal  fever,  should  seldom  be  less  than  twenty-four  ounces ; 
but  a  repetition  of  venesection  ought,  if  possible,  to  be  avoided, 
though  occasionally  it  may  be  absolutely  necessary ;  and  when 
this  is  the  case,  there  should  be  as  short  an  interval  as  possible 
between  the  first  and  second  bleeding,"  p.  76.  Why  this  direc- 
tion should  be  guarded  by  the  condition,  "absolutely  necessary," 
we  cannot  say,  as  we  presume,  in  such  cases,  when  employed,  it 
is  always  absolutely  necessary. 

We  are  very  desirous,  on  practical  points,  not  to  mislead,  by 
attaching  too  much  importance  to  any  mode  or  plan  we  may 
have  adopted  for  the  cure  of  a  disease,  when,  in  our  own  opinion, 
that  plan  has  not  been  sufficiently  tested  by  experience.  On  this 
account,  we  feel  that  we  are  not  in  possession  of  any  infallible 
marks,  by  which  we  can  distinguish  the  two  early  stages  of  this 
disease  from  each  other  better  than  those  who  have  preceded  us. 
We  can,  therefore,  only  give  a  detail  of  such  circumstances  as 
have  hitherto  directed  us  in  the  treatment  of  the  disease  in  ques- 
tion, and  have  led  us  to  suppose  we  were  generally  correct. 

We  believe  that  puerperal  fever  consists  in  a  most  active  in- 
flammation of  the  peritoneum ;  and  that  this  inflammation,  if  left 


408  PUERPERAL   FEVER. 

to  itself,  or  timidly  encountered,  or  if  aggravated  by  improper 
treatment,  will  run  its  first  stage  with  great  rapidity.  That  its 
second  stage  consists  in  the  termination  of  the  previous  inflam- 
matory stage,  in  that  state  known  by  the  term  "gangrene;" 
which  is  always  of  short  duration ;  for  it  either  retraces  its  steps 
to  inflammation,  or  resolution,  or  terminates  in  profuse  effusions 
within  the  cavity  of  the  abdomen.  That  the  only  chance  of  re- 
covery arises  from  the  immediate  extinction  of  the  inflammation 
by  resolution ;  and  that,  when  this  is  not  effected,  death  will  al- 
most inevitably  ensue ;  for,  unless  the  inflammatory  stage  can  be 
cured,  the  attempt  for  the  relief  of  the  others  is  altogether  con- 
tingent; as  all  experience,  or  with  extremely  rare  exceptions,  is 
much  against  favourable  results  from  any  mode  of  treatment  hi- 
therto pursued. 

We  have  thought  it  safe  and  necessary  to  bleed  in  puerperal 
fever,  as  long  as  the  pulse  possessed  any  firmness ;  the  abdomen 
great  tenderness  and  acuteness  of  feeling,  or  severe  occasional 
pain ;  provided  the  distention  was  not  great ;  and  while  the  mam- 
mee  secreted  milk,  or  they  retained  a  certain  degree  of  fulness, 
and  especially,  if  the  woman  exhibit  the  feelings  of  a  mother  to- 
wards her  child.  We  have  not  always  chosen  to  draw  the  blood 
by  the  lancet;  we  have  sometimes  preferred  the  employment  of 
leeches,  and  the  quantity  drawn  by  them  to  be  regulated  by  ounces, 
and  not  by  the  number  of  leeches.1 

We  desist  from  abstracting  blood  in  any  way,  when  we  believe 
our  second  stage  is  about  to  take  place,  or  has  actually  occurred. 
This  stage  Dr.  Armstrong  has  very  well  characterized  in  gene- 
ral ;  we  shall  therefore  repeat  it,  and  make  such  observations  as 
we  think  the  case  requires. 

"In  the  second  stage,  the  pulse  is  never  under  one  hundred 
and  forty,  and  frequently  rises  above  one  hundred  and  sixty  in 
the  minute,  while  it  is  always  exceedingly  variable,  weak,  and 
compressible ;  the  tenderness  of  the  belly  is  usually  much  dimi- 
nished, and  the  fulness  increased ;  cold  partial  perspirations  first 
break  out  about  the  face,  neck,  and  extremities ;  the  centre  of  the 
body,  particularly  the  surface  of  the  abdomen,  remaining  dry, 
and  of  a  pungent  heat,  for  some  time  afterwards.  The  patient 
rarely  shivers  much,  but  has  repeated  chills ;  vomits  dark,  gru- 

*  The  size  of  the  leech  in  this  country  not  only  varies  very  much,  but  also  is 
very  small  when  compared  with  the  European  leeches.  But  the  leechers  here 
soon  become  acquainted  with  the  capacities  of  these  animals,  and  will  very  accu- 
rately determine,  by  an  average,  the  quantity  of  blood  they  will  abstract.  As  a 
general  rule,  however,  eight  American  leeches  will  be  required  to  draw  an  ounce 
of  blood,  so  that  the  calculation  is  easily  made.  These  animals  should  be  applied 
to  the  abdomen  generally,  but  a  greater  number  should  be  placed  upon  the  most 
painful  portions  of  it,  or  they  may  be  placed  with  advantage  upon  the  inner  sur- 
face of  the  thighs. 


PUERPERAL    FEVER.  409 

mous  matter ;  seldom  breathes  less  than  sixty  times  in  a  minute ; 
has  generally  a  loose  belly,  a  brown,  black,  or  reddish  parched 
tongue ;  unquenchable  thirst,  tremulous  hands,  lightness  and 
swimming  in  the  head,  confusion  of  thought,  or  delirium :  and 
several  hours  before  death  a  remarkably  relaxed,  cold,  damp 
skin,"  p.  59. 

In  this  account,  Dr.  Armstrong  has  confounded  the  "  gangre- 
nous stage  "  with  the  "stage  of  effusion;"  some  of  the  symptoms 
belonging  to  the  one  are  blended  with  those  belonging  to  the 
other,  which,  for  the  sake  of  precision,  should  be  separated,  as 
the  stages  are  not  equally  desperate ;  for  the  gangrenous  may 
admit  of  remedy,  or  at  least  is  not  absolutely  fatal.  It  is,  how- 
ever, a  stage  necessarily  replete  with  danger,  though  it  may  not 
always  eventuate  in  death,  unless  goaded  to  it  by  a  mistaken 
theory,  or  a  false  pathology.  It  is  the  stage  in  which  bleeding 
can  never  be  proper ;  and  the  one  in  which  stimulants  must  be  for- 
bidden. It  is  the  one  in  which  we  must  always  rely  upon  the 
powers  of  the  system;  and,  consequently,  from  which  we  must 
not  look  for  many  recoveries,  though  we  may  have  a  right  to 
expect  now  and  then  an  escape. 

We  will  presently  attempt  to  separate  the  symptoms  which 
in  our  opinion  mark  these  two  stages. 


2.  Of  Purging. 

Nothing  can  be  said  in  favour  of  this  remedy  in  this  disease ; 
mild  aperients  may  be  occasionally  useful. 


3.  Of  Emetics. 

In  favour  of  emetics  in  puerperal  fever,  agreeably  to  a  plan 
suggested  by  M.  Doulcet,  there  is  the  most  extraordinary  testi- 
mony ever  presented  to  the  public.  In  1782  the  King  of  France 
directed  "the  Royal  Medical  Society  of  Paris"  to  make  a  re- 
port upon  the  memoir  of  this  gentleman,  containing  "a  new  me- 
thod of  treating  puerperal  fever."  This  report  declares  that 
"  puerperal  fever  had  made  its  appearance  more  frequently  than 
ever  in  the  Hotel  Dieu  of  Paris,  since  the  year  1774 ;  and  that 
it  had  always  proved  fatal  to  every  person  it  attacked.  They 
farther  report,  that  in  four  months,  during  which  this  epidemic 
disease  raged  with  great  fury,  nearly  two  hundred  women  were 
saved  to  society  by  Doulcet's  new  method  of  treatment." — 
Clarke's  Essays,  p.  106. 

M.  Doulcet's  method  of  cure  "consists  in  taking  the  advan- 


m    »• 


410  PUERPERAL    FEVER. 

tage  of  the  moment  of  attack,  and  giving,  without  losing  an  in- 
stant of  time,  fifteen  grains  of  ipecacuanha,  in  two  doses,  at  the  ' 
distance  of  an  hour  and  a  half  from  each  other,  and  repeating 
them  again  the  next  day,  in  the  same  manner,  whether  the  vio- 
lence of  the  symptoms  be  abated  or  not ;  and  if  the  disease  should 
continue  much  the  same,  they  are  repeated  again  the  third,  and 
even  the  fourth  day,  according  as  the  case  may  require.  In  the 
intervals  between  the  doses  the  effect  of  the  ipecacuanha  is  kept 
up  by  a  potion  composed  of  two  ounces  of  oil  of  sweet  almonds, 
one  ounce  of  syrup  of  marsh  mallows,  and  two  grains  of  Kermes" 
mineral.  The  common  drink  is  linseed  tea,  or  an  infusion  of 
Scorzonera  root,  edulcorated  with  syrup  of  althaea ;  and  towards 
the  seventh  or  eighth  day  of  the  disease,  the  patient  takes  a  mild 
purgative,  which  is  repeated  three  or  four  times,  according  to  the 
exigency  of  the  case.  The  efficacy  of  this  method  of  cure  con- 
sists wholly  in  its  early  application,  namely,  in  the  moment  when 
the  disease  first  commences ;  and  though  experience  has  since 
taught  us  that  the  loss  of  a  few  hours  is  not  always  irreparable, 
yet  it  seldom  happens  that  ipecacuanha  has  the  same  complete 
success,  when  the  first  moment  of  attack  is  lost." — Whitehead's 
Translation  of  Doulcet's  Method,  &c.,  as  quoted  by  Hull; 
Treatise  on  Phleg.  Dol.,  p.  267.  See  M.  Desormeaux's  Ac- 
count, p.  417. 

The  simplicity  of  M.  Doulcet's  plan  has  much  to  recommend 
it;  and  if  its  efficacy  had  been  equal  in  other  places,  and  in  other 
epidemical  puerperal  fevers,  as  it  was  in  that  of  the  Hotel  Dieu, 
it  would  be  irresistible.  But,  unfortunately  for  the  interests  of 
humanity,  the  success  of  this  plan  has  been  very  much  confined 
to  the  hands  of  its  inventor.  In  the  early  part  of  our  practice, 
we  adopted  this  plan  in  two  or  three  instances,  but  it  failed  alto- 
gether ;  neither  of  the  patients  having  survived  the  fifth  day. 
And  Dr.  Clarke  says,  "A  repetition  of  vomits  on  the  plan  sug- 
gested by  M.  Doulcet,  has  been  attended  with  obvious  disadvan- 
tage.— The  agitation  of  vomiting,  by  the  necessary  pressure  made 
on  the  contents  of  the  cavity  during  their  operation,  has  always 
aggravated  the  pain,  and  tends  farther  to  exhaust  the  powers  of 
the  woman,  already  sufficiently  reduced."  Essays,  p.  161. 

This  accords  precisely  with  what  was  observed  in  the  use  of 
emetics,  in  the  few  cases  in  which  we  exhibited  them.  And  this 
consequence  can  always  be  deduced,  when  the  vomiting  is  an  at- 
tendant on  puerperal  fever;  we  have  never  known  either  the 
spontaneous  or  provoked  puking  produce  a  favourable  change  in 
the  disease,  though  we  have  occasionally  witnessed  temporary 
relief,  when  bile  or  other  offensive  substances  have  been  thrown 
from  the  stomach. 

It  may  be  asked  how  it  has  happened  that  emetics  in  the 
hands  of  M.  Doulcet  should  have  been  invariably  successful,  and 


PUERPERAL    FEVER.  411 

fail  so  constantly  in  the  hands  of  others  ?  This  question  it  would 
be  difficult  perhaps  to  answer  satisfactorily ;  but  we  may  suggest 
that  it  might  have  depended  altogether  upon  some  peculiarity  of 
the  epidemic  itself,  but  of  which  peculiarity  we  have  no  know- 
ledge. It  was  certainly  of  less  rapid  course  than  those  of  Aber- 
deen or  Leeds ;  for  the  seventh  or  eighth  day  is  mentioned,  as 
if  it  were  a  common  period  to  arrive;  and  also,  that  they  found 
by  experience  that  the  loss  of  a  few  hours  was  not  irreparable ; 
the  very  reverse  of  the  two  epidemics  just  named.  It  seems  to 
have  borne  a  strong  resemblance  to  that  which  attacked  the 
"  Westminster  lying-in  Hospital,"  and  of  which  we  have  an  ac- 
count by  Dr.  Leake. 

The  occasional  use  of  emetics  is  recommended  by  Dr.  Den- 
man,  who  seems  to  be  convinced  of  their  utility ;  yet  it  would 
appear  that  the  benefit  procured  by  them  was  but  temporary, 
and  entirely  dependent  upon  the  condition  of  the  stomach.  For 
he  says,  "If  a  sickness,  loathing  of  stomach,  or  offensive  taste  in 
the  mouth  attend  the  commencement  of  the  disease,  this  medi- 
cine, (the  antimonial  powder,)  never  fails  to  occasion  vomiting, 
and  the  patient,  with  a  countenance  strongly  expressive  of  the 
benefit  she  has  received,  will  attest  the  advantage  of  the  method 
pursued."  But  it  must  be  remarked  that  Dr.  D.  in  no  instance 
relies  upon  this  method  exclusively;  for  he  says,  "At  the  same 
time  that  we  avail  ourselves  of  the  advantage  of  the  antimonial 
powder,  we  must  not  neglect  the  use  of  those  means  which  con- 
tribute to  procure  immediate  ease  or  relief  to  the  patient."  In- 
trod.  p.  281. 

From  what  has  just  been  said,  we  must  not  be  led  into  the 
belief,  that  the  nausea  and  bad  taste  in  the  mouth  are  always  in- 
dicative of  the  oppressed  state  of  the  stomach,  and  that  this  con- 
dition would  be  relieved  by  puking ;  for  we  must,  in  such  cases, 
be  careful  to  distinguish  between  the  sickness,  occasional  vomit- 
ing, and  disgust,  which  may  arise  from  something  offensive  in 
the  stomach,  and  the  vomiting,  &c.,  which  is  really  sometimes  a 
symptom  of  the  disease.  The  first  rarely  occurs  but  in  the  very 
commencement  of  the  disease,  while  the  other  only  appears  from 
one  to  several  days  after. 

The  vomiting  which  really  belongs  to  the  disease  is  seldom 
accompanied  by  the  discharge  of  crudities  from  the  stomach;  it 
merely  procures  the  discharge  of  mucus  and  the  drinks  taken 
down  a  short  time  before.  This  vomiting  arises,  either  from  the 
stomach  sympathizing  with  the  inflamed  peritoneum  at  a  dis- 
tance from  it,  or  from  its  own  covering  being  the  seat  of  it; 
both  of  which,  when  this  happens,  constitute  a  part  of  the  dis- 
ease, and,  of  course,  can  only  be  aggravated  by  the  use  of 
emetics. 

Dr.  Armstrong  is  decidedly  in  favour  of  emetics :  he  says,  "In 


412  PUERPERAL    FEVER. 

addition  to  bleeding  and  purging,  Mr.  Gregson  was  induced,  from 
an  accidental  circumstance,  to  prescribe  antimonial  emetics,  and 
on  repeated  trials,  fully  proved  them  to  be  excellent  auxiliaries, 
never  using  them,  however,  till  the  patient  had  been  freely  bled 
and  purged ;  and  this  is  certainly  the  best  way  of  administering 
them  in  puerperal  fever.  Three  very  severe  cases  which  I  at- 
tended were  treated  by  blood-letting,  purging,  and  vomiting, 
successively  employed  in  less  than  twelve  hours,  and  the  united 
influence  of  these  remedies  was  certainly  very  striking,  a  com- 
plete change  having  been  brought  about  in  the  circulatory  sys- 
tem, and  almost  every  symptom  of  inflammation  and  fever  en- 
tirely subdued,"  p.  68.  Mr.  Gregson,  in  his  communication  to 
Dr.  Armstrong,  says,  "My  attention  was  particularly  turned  to 
the  usefulness  of  emetics,  from  an  accidental  occurrence  in  a 
case  in  which  purgative  medicines  had  been  given  to  a  consi- 
derable extent,  without  completely  relieving  the  pain  and  tender- 
ness of  the  abdomen;  which,  however,  were  soon  removed  by 
free  vomiting,  occasioned  by  a  large  dose  of  calomel  and  jalap. 
And,  from  that  period,  I  have  repeatedly  used  antimonials,  with 
the  intention  of  exciting  nausea  or  vomiting,  when  bleeding  and 
purging,  or  when  purging,  alone,  had  been  premised,"  p.  113. 
Yet,  it  appears  to  us,  from  all  we  can  learn,  that  emetics  are  of 
doubtful  efficacy  as  principal  remedies ;  and  we  are  scarcely  dis- 
posed to  look  upon  them  as  useful  auxiliaries. 

LI   J»"it*  1  *f   *J  »r    v>  *'  *  *  ••'  *  * 
:^»    *T'  A         T>T  * 

4.  Blisters. 

Considerable  diversity  of  opinion  exists  with  regard  to  the 
propriety  of  applying  blisters  in  puerperal  fever.  Dr.  Clarke 
thinks  them  inconvenient,  and  of  very  doubtful  efficacy,  if  not 
injurious.  Dr.  Armstrong  is  of  opinion  they  may  be  useful,  if 
applied  before  the  second  stage  commences ;  but  confesses  that 
since  he  had  bled  and  purged  so  freely,  that  he  had  rarely  found 
it  necessary  to  employ  them.  Mr.  Hey  considers  them  incon- 
venient ;  and  that  they  will  seldom  be  necessary ;  but  has  thought 
them  useful  if  applied  before  the  last  stage.  See  Chap,  on  In- 
flammation *of  the  Uterus. 

Our  own  opinion  is,  that  they  are  less  useful  in  this  inflamma- 
tion than  in  any  other:  we  have  used  them  formerly,  but  have 
abandoned  them  altogether  of  late  years;  because  they  are  al- 
ways extremely  inconvenient,  where  the  patient  is  to  be  so  fre- 
quently disturbed  by  the  operation  of  purgative  medicine,  and 
never,  as  far  as  we  have  seen,  decidedly  useful.  If  they  are 
employed,  it  should  be  after  the  first  or  second  liberal  bleeding, 
and  after  the  bowels  have  been  well  purged,  and  the  inside  of 
the  thighs  should  be  their  seat. 

1   *  -  «        f '  •'}£   '.'  W~*  fc-  ***  *  *    " 


PUERPERAL    FEVER.  413 


5.  Fomentations. 

Many  are  in  the  habit  of  employing  -warm  fomentations  to  the 
abdomen  ;  Mr.  Hey  recommends  them  as  soothing,  and  as  free 
from  mischief.  We  have  for  many  years  ceased  to  employ  them, 
for  the  following  reasons  :  first,  they  are  oppressive  from  their 
weight,  and  offensive  from  the  vapour  which  arises  from  them  ; 
secondly,  they  expose  the  woman  to  injury  from  her  bed  be- 
coming wet,  against  which  no  care  can  guard  ;  thirdly,  they  op- 
press from  their  heat,  and  appear  always  to  increase  the  fre- 
quency of  the  pulse  ;  fourthly,  we  have  never  seen  them  of  the 
smallest  benefit.  Bladders,  partially  filled  with  warm  water,  are 
the  best  mode  of  applying  fomentations,  if  they  be  insisted  on. 


6.  Spirit  of  Turpentine. 

Were  we  to  pass  this  substance  unnoticed,  it  might  be  looked 
upon  as  an  important  omission.  The  character  it  has  obtained 
with  many  respectable  physicians  will  always  justify  a  trial ; 
but  we  are  sorry  to  say  that  so  far,  in  our  hands,  we  have  not 
had  sufficient  reason  to  rely  solely  upon  it ;  though  as  an  auxi- 
liary, in  two  or  three  recent  instances,  we  thought  it  highly 
useful. 

We  confess  ourselves,  however,  to  have  laboured  under  preju- 
dices, or  rather  apprehensions  of  its  effects  in  the  beginning  of 
the  disease,  or  as  a  substitute  for  bleeding  and  purging,  as  recom- 
mended by  Dr.  Brenan.  As  we  are  not  familiar  with  its  use,  or 
acquainted  from  experience  with  either  the  proper  moment  for  its 
employment,  or  the  proper  quantity  to  be  exhibited  under  varying 
circumstances,  it  appears,  at  present,  at  least,  a  doubtful  remedy ; 
yet  we  would  not  wish  to  be  understood,  by  this  declaration,  as 
doubting  the  veracity,  or  impugning  the  motives,  of  those  who 
have  borne  unqualified  testimony  to  its  control  over  this  disease. 

Our  want  of  extensive  experience  in  this  remedy  will  only 
permit  us  to  say  that  it  appears  to  be  only  proper  at  the  termina- 
tion of  the  first  stage ;  here  it  may  be  useful ;  but  here  we  have 
forbidden  stimulants.  But  is  this  substance  to  be  ranked  under 
the  same  head  with  wine,  brandy,  opium,  volatile  alkali,  &c.? 
We  think  not,  for  it  appears  to  be  a  stimulus  of  peculiar  powers, 
as  we  see  in  burns,  &c.  Were  we  to  suggest  then  a  trial  of  the 
sp.  tereb.,  it  would  be  at  the  period  just  designated,  and  in  com- 
bination with  castor  oil ;  thereby  forming  one  of  the  most  certain 


414  PUERPERAL  FEVER. 

and  peculiar  cathartics  we  know.     It  might  deserve  a  trial  at 
this  period.1 


7.  Mercurial  Frictions. 

This  remedy  has  lately  been  proposed  for  puerperal  fever ;  and 
M.  Velpeau  has  given  in  "Revue  Medicale,"  for  January,  1827, 
several  very  interesting  cases,  in  which  was  employed,  and  appa- 
rently with  advantage,  .mercurial  frictions  upon  the  abdomen. 
But  he  very  honestly  confesses  his  experience  to  be  insufficient, 
at  the  time  he  wrote  his  essay,  to  determine  the  precise  degree 
of  confidence  to  be  placed  upon  his  plan ;  yet  he  appears  pretty 
strongly  inclined  to  attach  considerable  importance  to  it.  His 
mode  of  using  this  remedy  is —  . 

First,  To  have  the  whole  abdomen  smeared  with  from  two  to 
four  drachms  of  the  unguent,  every  two,  three,  or  four  hours. 

Secondly,  If  the  pain  and  swelling  of  the  abdomen,  and  espe- 
cially if  the  mouth  betray  any  mark  of  the  influence  of  the  mer- 
cury upon  it,  to  dimmish  the  quantity  to  one  or  two  drachms, 
and  to  make  the  intervals  of  application  longer.2 

Thirdly,  to  wash  off,  with  warm  water  and  soap,  or  with 
sweet  oil,  the  crust  which  the  ointment  forms  upon  the  skin,  that 

1  The  following  case  has  occurred  to  us  since  the  period  of  the  above  remarks. 

May  10th,  1830,  5  o'clock,  P.  M.  Was  called  to  visit  Mrs.  L.,  in  consultation 
with  Drs.  Zorn,  Perkin,  and  Shaeffer.  Mrs.  L.  was  safely  delivered  two  days  pre- 
viously, though  considerable  hemorrhage  succeeded.  Soon  after  the  abatement  of 
the  flooding,  she  was  attacked  with  severe  pain  in  the  abdomen,  followed  by  great 
distention  and  tenderness,  great  distress  of  stomach  and  wmiting,  &c.,  which 
continued  with  unabated  viqlence  up  to  the  moment  of  my  first  visit.  She  was  at 
this  moment  vomiting  violently,  and  discharging  very  large  quantities  of  a  dark 
green-coloured  fluid,  and  quadruple  or  more  than  the  quantity  drank.  Her  pulse 
very  small,  and  so  frequent  as  scarcely  to  be  counted;  extremities  cold,  and  her 
whole  body  covered  with  cold  sweat;  breathing  laborious;  her  abdomen  enormously 
distended,  and  extremely  sore  to  the  touch.  We  retired,  and  I  really  looked  upon 
the  case  as  utterly  beyond  the  reach  of  remedy.  But  as  it  was  very  proper  to 
make  some  effort  for  the  relief  of  the  patient,  it  was  agreed  that  twenty  or  thirty 
drops  of  the  spirit  of  turpentine  should  be  given  every  hour,  and  the  whole  of  the 
abdomen  covered  with  ung.  hydrargyr.  fort,  without  regard  to  weight.  As  the 
case  was  so  utterly  forlorn,  an  appointment  for  meeting  was  not  formally  made — 
another  consultation  was  left  to  the  contingency  of  her  surviving  the  night,  1 1th, 
I  was  agreeably  surprised  by  a  request  to  meet  the  above  named  gentlemen  at  1) 
o'clock,  A.  M.  We  found  our  patient  much  relieved  of  every  enumerated  symp- 
tom— the  remedies  were  continued,  and  her  amendment  under  it  so  rapid,  that  I 
withdrew  from  the  consultation  on  the  fourth  day  from  my  first  visit.  In  a  short 
time  after  I  was  informed  by  Dr.  Perkin  that  Mrs.  L.  was  entirely  recovered. 
In  this  case  the  turpentine  appeared  to  have  a  most  decided  control  over  the  dis- 
ease— it  was  probably  aided,  however,  by  the  mercurial  ointment.  In  another 
case,  soon  after  this,  however?  the  turpentine  and  mercurial  ointment  failed,  though 
the  case  \vas  neither  so  rapid  in  its  progress  nor  so  violent  in  its  symptoms,  for 
the  patient  continued  until  the  seventh  day. 

*  In  neither  of  the  cases  in  which  we  used  the  mercurial  ointment  were  the 
salivary  glands  affected  in  the  slightest  degree. 


PUERPERAL    FEVER.  415 

in  its  future  application  it  may  be  more  certainly  placed  in  con- 
tact with  the  skin. 

Fourthly,  To  continue  the  ointment,  if  circumstances  warrant 
it,  (that  is,  if  the  patient  live  long  enough,  or  if  her  system  be 
obedient  to  its  influence,)  until  either  signs  of  salivation  show 
themselves,  or  until  such  amendment  take  place,  as  shall  render 
farther  perseverance  unnecessary. 

A  very  interesting  case  of  puerperal  fever  has  lately  presented 
itself,  in  which  the  mercurial  ointment  was  very  liberally  used ; 
but  I  should  be  very  unwilling  to  decide  upon  the  extent  of  the 
agency  it  had  in  the  recovery  of  the  patient,  as  another  cele- 
brated remedy  was  employed  simultaneously  with  it;  namely, 
the  spirit  of  turpentine. 

I  was  requested  by  Dr.  Mitchell  to  visit  Mrs. ,  who  was 

very  ill  with  puerperal  fever.  This  patient  had  been  delivered 
safely  by  the  Dr.  of  her  first  child,  and  nothing  alarming  pre- 
sented itself  until  the  second  day.  Milk  had  been  freely  se- 
creted, and  there  was  every  promise  of  a  good  "getting  up," 
until  the  beginning  of  the  third.  At  this  time  she  was  attacked 
with  a  pretty  severe  chill,  which  was  followed  by  great  heat, 
thirst,  tenderness  of  the  abdomen,  and  a  very  frequent  pulse. 

She  was  bled,  purged,  leeched,  and  blistered  on  the  abdomen, 
and  kept  upon  a  strict  antiphlogistic  regimen,  &c.,  before  I  saw 
her.  There  was  such  an  appearance  of  amendment  for  two  or 
three  days  after  this  time,  that  scarcely  a  fear  was  felt  but  that 
she  would  surmount  her  disease ;  but  the  expectations  so  fondly 
indulged  in  in  the  morning,  were  entirely  destroyed  in  the  eve- 
ning, by  finding  our  patient  with  a  cold,  clammy  skin ;  a  pulse 
scarcely  to  be  numbered,  very  small,  nay,  almost  extinct; 
breathing  short,  very  frequent,  and  rather  laborious ;  the  alee 
nasi  expanding  and  contracting  with  great  frequency ;  the  sto- 
mach rejecting  every  thing  offered  to  it;  the  lips  dark  and  dry; 
the  milk  entirely  gone;  slight  mental  alienation,  though  not 
amounting  to  delirium;  the  abdomen  excessively  distended  and 
tympanitic;  the  feet  and  legs  cold;  extreme  foetor  of  the  lochia, 
which  were  small  in  quantity,  and  very  dark ;  in  a  word,  so  cer- 
tainly did  we  look  upon  her  being  in  articulo  mortis,  that  no  ap- 
pointment was  made  for  a  visit  next  morning. 

Notwithstanding,  however,  these  unfavourable  appearances, 
Dr.  M.  and  myself  thought  it  a  duty  to  do  every  thing  that  lay 
in  our  power — accordingly,  thirty  drops  of  the  spirit  of  turpen- 
tine were  ordered  to  be  given  every  hour:  an  ounce  of  strong 
mercurial  ointment  was  directed  to  be  rubbed  on  the  abdomen 
during  the  night,  sinapisms  were  ordered  to  the  feet  and  legs, 
and  an  enema  of  sixty  drops  of  laudanum  and  a  gill  of  warm 
water  was  to  be  thrown  up  the  rectum. 

The  next  morning  Dr.  M.  favoured  me  with  a  call,  as  had  been 


416  PUERPERAL    PEVER. 

agreed  upon  the  evening  before,  provided  he  found  the  patient 
alive.  And  I  honestly  confess,  I  was  much  surprised  when  he 
reported  our  patient  to  be  rather  better  than  we  had  left  her 
in  the  evening.  Upon  visiting  her,  this  was  found  to  be  the  case. 
The  skin  and  extremities  were  warm ;  the  pulse  more  expanded, 
and  considerably  less  frequent ;  her  breathing  more  natural ;  the 
countenance  more  composed  ;  the  mind  more  upon  the  alert ;  the 
vomiting  and  nausea  greatly  subsided ;  the  abdomen  rather  less 
tender.  The  ointment  was  to  be  continued,  as  well  as  the  tur- 
pentine :  of  the  latter  she  complained,  as  creating  a  disagreeable 
heat  in  the  stomach.  To  remedy  this,  a  tea-spoonful  of  sweet 
oil  was  directed  to  follow,  in  fifteen  minutes,  each  dose  of  the 
turpentine,  which  effectually  removed  this  inconvenience. 

Barley  water  and  very  thin  sago  were  directed  as  drink  and 
nourishment;  also  the  juice  of  sweet  oranges,  which  proved  very 
refreshing.  The  remedies  were  ordered  to  be  continued  in  the 
evening.  On  the  morning  following  there  was  so  much  amend- 
ment that  the  turpentine  was  discontinued:  the  pulse  was  still 
too  frequent,  but  the  abdomen  was  less  swelled,  much  softened, 
and  very  much  less  tender.  The  ointment,  however,  was  again 
applied.  From  this  time  she  improved  hourly,  and  had  even- 
tually a  rapid  convalescence. 

During  the  whole  treatment,  it  may  be  proper  to  observe,  that 
a  solution  of  gum  Arabic  was  her  chief  food  and  drink ;  and  that 
at  no  time  were  internal  stimulants,  if  we  except  the  turpentine, 
for  an  instant  employed. 

I  have  since  been  informed  by  Dr.  M.,  that  four  or  five  days 
after  I  had  taken  my  leave  of  this  patient,  that  upon  her  com- 
plaining of  some  pain  in  her  bowels,  the  nurse,  (a  new  one,)  gave 
her  some  brandy  to  relieve  it:  this  immediately  exasperated  the 
pain,  and  re-excited  fever.  She  was  under  the  necessity  of 
losing  twelve  ounces  of  blood,  and  to  be  purged,  which  soon  re- 
lieved the  pain  and  fever :  she  recovered  soon  after  this  without 
farther  interruption. 

It  may  be  as  important,  as  it  is  interesting,  to  state,  that  after 
an  entire  cessation  of  the  milk  for  two  weeks,  it  was  restored, 
and  continues  sufficient  to  nourish  the  child:  this  was  effected 
by  the  persevering  application  of  the  child  to  the  breast. 

b.   The  gangrenous  Stage? 

We  believe  that  from  the  moment  that  the  pulse  increases  in 
frequency,  from  one  hundred  and  twenty,  to  one  hundred  and 

1  "  Gangrene  may  be  considered  as  a  partial  death;  the  death  of  one  part  of  the 
body,  while  the  other  parts  retain  their  natural  powers."  Sir  Astley  Cooper's 
Lectures,  Am.  Ed.  p.  98. 

The  state  of  a  part  here  described  it  not  precisely  what  we  would  wish  to  be 


PUERPERAL   FEVER.  417 

forty,  the  system  is  verging  towards  the  second,  or  gangrenous 
stage.  At  this  time  the  pulse  not  only  increases  in  frequency, 
but  also  abates  in  force,  and  even  perhaps  in  volume.  Hiccough 
now  takes  place,  with  more  or  less  violence.  The  mammse  lose 
their  milk  entirely,  and  become  more  flaccid.  Vomiting  of  the 
drinks,  almost  as  soon  as  swallowed,  sometimes  takes  place.  The 
tenderness  of  the  abdomen  is  diminished;  and  the  character  of 
the  pain  changes  from  the  acute  "to  the  obtuse;  the  swelling 
is  increased  in  the  belly,  and  an  approach  to  tympanitis  may  be 
perceived  by  striking  against  its  sides.  The  urine  is  extremely 
high-coloured,  offensive  in  smell,  and  very  scanty  in  quantity. 
If  there  be  lochia,  they  are  offensive  and  very  dark.  A  lividity 
commences  on  the  cheek  and  lips.  The  mouth  is  dark-coloured, 
and  parched ;  the  tongue  is  generally,  but  not  necessarily,  dry  and 
rough ;  but  when  so,  it  requires  several  efforts  to  thrust  it  beyond 
the  teeth;  and  when  placed  thus,  it  is  either  not  retracted  until 
the  patient  is  bidden  to  do  so,  or  is  withdrawn  very  slowly  and 
reluctantly.  The  teeth  are  covered  with  a  mahogany-coloured 
scruff,  and  the  gums  nearly  livid.  The  skin  is  dry  and  husky. 
The  respiration  hurried,  and  rather  laborious ;  but  not  so  frequent 
as  the  last  stage,  though  much  more  so  than  the  first. 

A  tendency  to  delirium,  or  a  manifest  forgetfulness  of  the  im- 
mediately preceding  events;  a  total  indifference  to  the  child 
and  the  surrounding  circumstances.  Complains  but  little ;  and, 
if  interrogated,  answers  vaguely,  or  contradictorily.  The  pulse 
is  rapid  and  rather  indistinct;  and  the  wrists  colder  than  the 
other  portions  of  the  arms.  This  stage  is  very  evanescent ;  rare- 
ly continuing  more  than  twelve  hours,  though  it  may,  perhaps, 
be  protracted  a  little  longer  by  proper  remedies ;  or  be  shortened 
by  improper  ones. 

It  is  this  stage  which  receives  the  name  of  typhus ;  it  is  at 
this  time  that  the  nature  of  the  remedies  is  changed  by  most 
practitioners ;  and  it  is  •  at  this  period  that  this  change  usually 
seals  the  fate  of  the  patient. 

The  management  of  this  stage  should  be  reduced  to  one  of 

understood,  when  we  describe  "the  gangrenous  state  of  puerperal  fever,"  there- 
fore, we  would  wish  to  employ  precisely  the  definition  which  Galen  gave  of  gan- 
grene :  which  is  that  state  or  condition  "when  a  part,  from  violent  inflammation, 
is  not  absolutely  dead,  but  is  about  to  die."  Huger's  Inaugural  Dis.  on  Gangrene 
and  Mortification,  p.  6. 

Dr.  Armstrong  says  that  "medical  writers  have  justly  made  a  distinction  be- 
tween gangrene  and  sphacelus;  the  circulation,  animal  heat,  and  .sensibility  re- 
maining in  the  first,  but  not  in  the  last;  the  one  being  the  threatened,  the  other 
the  actual,  death  of  the  part."  Morbid  Anatomy,  p.  78. 

In  this  state  of  a  part,  the  previous  action  or  inflammation  exceeds  the  powers 
of  the  part  to  sustain  that  action;  and,  consequently,  there  exists  a  great  dispro- 
portion between  the  action  and  the  power.  Now,  it  must  be  evident  in  such  a 
case,  that  the  only  relief  that  can  be  expected,  is  from  a  reduction  of  the  action 
to  the  state  of  the  power,  as  we  shall  state  more  fully  presently. 

27 


418  PUERPERAL   FEVER. 

great  simplicity  and  inertness,  by  withholding  all  stimuli ;  but 
continuing  a  gentle  depletion  from  the  bowels.1  Diarrhoea  some- 
times comes  on  at  this  stage,  and  occasionally  proves  critical,  if 
it  be  not  arrested  upon  false  principles,  by  astringents.  The  sys- 
tem sometimes  rights  itself,  when  it  is  not  opposed  by  officious- 
ness  or  overweening  anxiety ;  or  is  not  overturned  by  stimulation. 
Has  any  one  seen  a  recovery  from  this  stage,  when  bark,  wine, 
opium,  ammonia,  &c.,  have  been  employed?  We  believe  few 
can  answer  this  question  in  the  affirmative.  Even  under  the 
management  of  the  judicious  Hey,  we  have  reason  to  believe,  in 
one  or  two  instances,  he  but  hastened  the  fate  of  his  patients. 
See  cases  IX.,  XXVII.  Dr.  Armstrong,  though  he  does  not  ap- 
pear to  recognise  the  exact  condition  of  the  system  at  this  period, 
was  nevertheless  perfectly  aware  of  the  injurious  tendency  of 
cordials,  or  of  stimulants. 

The  views  of  Mr.  Hunter,  on  the  subject  of  inflammation  and 
Its  consequences,  are  truly  valuable,  and  every  way  in  point,  as 
regards  our  present  subject.  He  says,  "  I  consider  inflammation 
as  an  increased  action  of  that  power  which  a  part  naturally  pos- 
sesses ;  and  in  healthy  inflammations,  at  least,  it  is  probably  at- 
tended with  an  increase  of  power;  but  in  inflammations  which 
terminate  in  mortification,  there  is  no  increase  of  power,  but,  on 
the  contrary,  a  diminution  of  it.  This,  when  joined  to  an  in- 
creased action,  becomes  a  cause  of  mortification,  by  destroying 
the  balance  which  ought  to  subsist  between  the  action  and  the 
power  of  every  part.  If  this  account  of  mortification  arising 
from  no  specific  nature  be  just,  we  shall  find  it  no  difficult  mat- 
ter to  establish  a  rational  mode  of  cure ;  but,  before  we  do  this, 
let  us  take  a  view  of  the  treatment  which  has  hitherto  been  re- 
commended, and  see  how  far  it  agrees  with  our  theory!  It  is 
plain,  from  the  common  practice,  that  the  weakness  has  been  at- 
tended to;  but  it  is  also  plain  that  the  increased  action  has  been 
overlooked;  and,  therefore,  the  whole  aim  has  been  to  increase 
the  action,  in  order  to  remove  the  weakness. 

"The  Peruvian  bark,  confectio  cardiaca,  serpentaria,  &c., 
have  been  given  in  as  large  quantities  as  the  case  appeared  to 
require  or  the  constitution  could  bear;  by  which  means  an  arti- 
ficial or  temporary  appearance  of  strength  has  been  produced, 

*  Maintaining  the  depletion  of  the  bowels  is  in  strict  conformity  to  the  theory 
adopted  of  this  complaint — for  the  augmented  secretion  from  the  mucous  surface 
of  the  bowels  acts  like  topical  depletion,  as  it  must  necessarily  diminish  the 
•contents  of  the  vessels  concerned  in  the  inflammation,  and  thus  permit  them  to 
contract;  and  by  contracting,  they  acquire  an  increase  of  power,  and,  at  the  same 
time,  suffer  a  diminution  of  action;  because  one  of  the  unnatural  stimuli  is,  in  part, 
withdrawn;  namely,  that  of  distention.  Mr.  Hunter  says,  that  "many  circum- 
stances in  life,  as  also  many  applications  to  parts,  will  call  forth  the  contraction 
of  the  vessels :  we  are,  therefore,  to  apply  such  means ;  and  whatever  will  do  this 
without  irritation,  will  so  far  counteract  the  effects," — Treatise  on  the  Blood, 
Am.  Ed.  p.  279. 


PUERPERAL    FEVER.  419 

while  it  was  only  an  increased  action.  Cordials  and  wine,  upon 
the  principle  on  which  they  have  been  given,  are  rationally  ad- 
ministered ;  but  there  are  strong  reasons  for  not  recommending 
them,  arising  from  the  general  effect  which  they  possess,  of  in- 
creasing the  action,  without  giving  real  strength.  The  powers 
of  the  body  are,  by  this  treatment,  sunk  afterwards  in  the  same 
proportion  as  they  had  been  raised,  by  which  nothing  can  be 
gained,  but  a  great  deal  may  be  lost;  for,  in  all  cases,  if  the 
powers  are  allowed  to  sink  below  a  certain  point,  they  are  irre- 
coverable."— Introd.  to  Treatise  on  the  Blood,  p.  20. 

Dr.  Armstrong  also  states,  p.  63,  "  The  stimulant  treatment, 
(in  the  second  stage,)  is,  at  once,  the  most  delusive  and  danger- 
ous which  can  be  adopted,  and  it  is  much  to  be  lamented  that  it 
has  the  weight  and  authority  of  some  eminent  names."  Again, 
p.  81,  he  observes,  that  "  the  system  is  uncommonly  susceptible 
of  stimulants,  such  as  strong  wine  and  cordials  in  the  second 
stage,  and,  if  freely  administered,  they  generally  destroy  the 
patient,  whose  remaining  powers  are  best  supported  by  milk, 
nourishing  broths,  and  the  like." 

He  also  appears  well  acquainted  with  the  propriety,  nay,  the 
necessity,  of  continuing  the  discharges  from  the  bowels.  He  says, 
"  Speaking  from  my  own  personal  observation,  I  do  not  know 
the  period  of  the  disease  in  which  cathartics  can  be  omitted  with- 
out considerable  hazard;  they  are  indispensable  in  the  first  stage, 
and  I  have  seen  them  occasionally  succeed  when  the  disorder 
seemed  advanced  into  the  second,"1  p.  80. 

Mr.  Hey  says,  "If  these  means,  (evacuants,)  fail  to  cure  the 
disease,  from  being  employed  either  too  late,  or  in  an  improper 
manner,  grateful  cordials  may  be  given  in  its  latter  stages  to  al- 
leviate the  distressing  feelings  of  the  patient;  but  cordials  or  to- 
nics can  afford  no  other  advantage,"  p.  166.  As  we  cannot  appre- 
ciate exactly  the  powers  of  the  system,  when  under  disease,  how- 
ever desperate  that  disease  may  be,  is  it  not  improper,  from  any 
motive  of  humanity,  to  give  that  which  cannot  relieve,  but  which 
may  injure  by  interrupting  the  powers  of  the  system,  in  an  at- 
tempt at  restoration  ?  In  the  stage  we  are  now  considering,  the 
patient's  safety  depends  upon  "doing"  (almost)  "nothing." 
Light  vegetable  jellies,  acidulated  by  the  sulphuric  .acid;  gum 
Arabic  in  solution,  acidulated;  rennet-whey;  cream  of  rice. 
Strong  coffee  is  often  very  grateful,  and  sits  well  upon  the  sto- 

1  It  must,  however,  be  understood,  that  purging  must  not  be  carried  on  to  the 
same  extent  as  in  the  more  active  stage  of  the  disease;  for,  if  carried  too  far,  it 
may  irritate  the  bowels  too  severely,  and  thus  increase  the  debility.  Mr.  Hey's 
plan,  of  an  evacuation  every  few  hours,  is  perhaps  rather  excessive;  we  shouM 
prefer  a  less  to  a  greater  number,  and  for  the  reasons  before  stated;  a  less  num- 
ber would  seem  every  way  sufficient  for  the  removal  of  offensive  matters  in  toe 
intestines,  besides  occasioning  a  competent  increase  of  serous  secretion. 


420  PUERPERAL    FEVER. 

mach,  and  may  be  administered  freely,  especially  if  vomiting  be 
troublesome.  We  cannot  agree  with  Dr.  Armstrong,  and  Mr. 
Hey,  in  the  use  of  broths,  or  any  other  animal  substance ;  for, 
in  our  opinion,  they  should  always  be  excluded  from  the  room 
of  the  puerperal  patient.  In  the  early  stage  they  are  too  sti- 
mulating ;  and  in  the  second,  too  soon  become  decomposed  in  the 
bowels,  and  add  to  the  existing  mischief.  Drinks  may  be  given 
freely,  and  may  be  made  to  convey  sufficient  nourishment;  but 
they  must  have  in  them  no  stimulating  ingredient  whatever. 
Saline  draughts  in  a  state  of  effervescence,  Mr.  Hey  says,  are  re- 
freshing ;  they  may,  therefore,  be  given ;  the  sweet  spirit  of  ni- 
tre, also,  makes  an  agreeable  beverage. 

tinder  some  of  the  most  unfavourable  conditions  of  the  system 
in  this  disea&e,  there  have  occasionally  been  recoveries;  such 
are  the  cases  of  Dr.  Gordon,  after  effusion,  and  others,  per- 
haps, whose  exact  histories  we  are  not  acquainted  with.  The 
restorative  powers  of  the  system  in  some  instances  are  great ;. 
and  they  are  occasionally  exerted  successfully,  under  circum- 
stances where  no  reasoning  upon  the  subject  could  for  a  mo- 
ment justify  a  hope ;  thus,  women  have  recovered  after  rupture 
of  the  uterus,  &c.  But  in  all  these  eases,  nature  was  freed  as 
much  as  possible  from  as  many  of  the  retarding  causes  as  it  well 
could  be,  and  left  to  manage  the  injury  in  her  own  way.  So, 
in  the  disease  under  consideration,  were  nature  left  undisturbed 
to  the  exercise  of  her  powers,  we  should,  perhaps,  have  more  in- 
stances of  recovery. 

The  system  sometimes  recovers  itself  from  this  gangrenous 
state  of  fever  by  means  of  its  own,  when  it  is  not  stimulated  to 
unnecessary,  or  rather  to  deadly,  exertion;  but  after  a  manner 
which  can  neither  be  foreseen  nor  imitated.  Thus,  we  have  seen 
recoveries  from  yellow  fever,  after  black  vomit  and  hemorrhages 
from  almost  every  part  of  the  body;  but  in  all  these  instances, 
little  was  done  towards  aiding  nature;  she  was  permitted  to  do 
her  work  in  her  own  way. 

Yet  there  are  instances  in  which  the  system  can  be  much  as- 
sisted, even  in  desperate  cases,  when  the  indications  are  obvious, 
and  of  easy  execution ;  as  the  following  case  will  prove : — 

A  young  man,  of  strong  constitution,  was  attacked  with  a 
bilious  remittent  fever,  which,  after  fourteen  days,  took  on  the 
form  of  typhus,  as  it  was  called ;  and  for  which,  bark,  wine  and 
blisters  were  employed.  On  the  seventeenth  day  of  the  disease, 
I  was  called  on  to  visit  him.  I  found  the  patient  with  a  quick, 
irregular,  and  tense  pulse;  and  the  sores  occasioned  by  the  blis- 
ters, quite  livid.  The  bark  and  wine  were  omitted ;  the  patient 
was  bled  and  purged ;  and  all  applications  to  the  blistered  parts 
were  forbidden.  The  following  day  he  was  better ;  but  his  pulse 


421 

continuing  tense,  he  was  again  bled,  and  purged  with  calomel 
and  jalap.  He  continued  to  mend;  the  livid  look  of  the  blistered 
parts  was  converted  into  one  of  high  inflammation.  He  was  bled 
once  more :  the  fever  left  him  a  few  days  after  ;  the  sores  healed 
kindly,  and  he  was  soon  perfectly  well.  Here,  from  a  state  of 
most  violent  action,  by  removing  the  irritating  cause,  and  lower- 
ing the  system,  the  action  of  the  parts  retrograde,  first  to  that 
of  active  inflammation,  and  then  to  that  degree  of  it  only  that 
was  necessary  to  the  restoration  of  the  parts  which  have  suffered 
from  the  over-stimulation  of  the  blisters. 


3.  Stage  of  Effusion. 

This  stage  is  one  of  almost  entire  hopelessness ;  the  wretched 
patient  must,  in  great  measure,  be  abandoned  to  her  fate,  as  re- 
gards medical  treatment ;  but,  if  comfort  of  any  kind  can  be  af- 
forded her,  it  may  be  given  with  as  liberal  a  hand  as  her  de- 
mands require.  Stimulants,  cordials,  opiates,  may  be  adminis- 
tered without  reserve  or  apprehension;  for  the  disease  has  spent 
upon  her  the  full  force  of  its  powers ;  for  in  this  instance  we  do 
not  know  what  can  injure,  or  what  can  benefit,  the  case ;  in  this 
stage,  then,  we  may  depart  from  the  rule  laid  down  in  the  se- 
cond. 

There  is  something  remarkable  in  the  tendencies  of  this  dis- 
ease to  gangrene,  (in  our  acceptation  of  the  word,  see  p.  416,) 
and  from  gangrene  to  extensive  effusion.  It  is  this  act  of  effu- 
sion that  prevents  the  inflammation  from  ending  in  sphacelus ; 
and  well  accounts  for  Dr.  Clarke  not  finding  "  the  parts  in  a  state 
of  gangrene,"  (sphacelus.)  • 

The  effusion  is  not  only  sometimes  excessive,  (see  p.  357,  &c.,) 
but  must  be  looked  upon  as  almost  necessarily  fatal.1  This  ef- 
fort of  the  over-exerted  vessels  is  marked  by  the  following  symp- 
toms : — 

Pulse  fluttering,  and  scarcely  to  be  numbered ;  the  belly  enor- 
mously swelled,  and  tympanitic;  cold  sweats  over  the  whole 
body,  or  confined  to  the  face  and  extremities.  The  skin  on  the 
hands  sometimes  is  shrivelled,  as  if  they  had  been  immersed  in 
warm  water  for  a  long  time;  repeated  chilliness,  without  reac- 
tion ;  vomiting,  or  rather  gulping  up,  a  dark  brown,  or  coffee- 
coloured  fluid;  involuntary  stools,  and  sometimes  a  profuse  dis- 

1  "  The  mischief  which  takes  place  in  the  cavity  of  the  abdomen,  whether 
by  extravasation,  suppuration,  or  gangrene,  renders  the  disease  incurable ;  ex- 
cept in  the  two  former  cases,  by  some  extraordinary  efforts  of  nature,  of  which 
Dr.  Gordon  has  related  three  instances,  where  the  confined  fluid  made  its  way  by 
a  direct  outlet;  in  two  at  the  umbilicus,  and  in  the  third  by  the  urethra." — Hey, 
p,  Ifc6. 


422  PUERPERAL    FEVER. 

charge  from  the  uterus,  of  a  bloody  sanies  or  black  grume.  De- 
lirium, or  perfect  collectedness ;  the  tongue  frequently  moist,  and 
an  attempt  is  sometimes  made  at  cleaning;  (sometimes,)  convul- 
sions; death. 


SBCT.   VIII. — General  Directions  and  Rules. 

It  is  of  the  utmost  consequence  to  the  woman  labouring  under 
puerperal  fever,  that  her  nurse  or  attendant  should  be  faithful  in 
the  discharge  of  her  duties ;  that  she  have  sufficient  understanding 
to  comprehend  the  directions  of  the  physician ;  enough  good  sense 
and  fidelity  to  put  them  in  practice;  resolution  to  withstand  the 
•wayward  and  improper  demands  of  the  patient,  should  they  be 
made  ;  and  courage  enough  to  bear  up  against  the  encroachments 
of  friends,  and  the  preposterous  recommendations  of  visiters. 

Every  direction  of  the  physician  should  be  most  promptly  put 
in  practice  by  the  nurse,  or  other  attendants ;  and  that  it  may 
be  done  to  the  letter,  it  should  be  impressed  again  and  again 
upon  the  minds  of  those  who  may  have  charge  of  the  sick,  by 
delivering  them  circumstantially,  and  without  ambiguity,  or  the 
possibility  of  misapprehension.  Nothing  should  be  left  to  con- 
struction ;  the  directions  must  be  so  peremptory  and  clear  as  to 
prevent  the  possibility  of  subterfuge.  To  ensure  this  in  the  best 
manner,  the  physician  should  ascertain,  at  each  visit,  whether  his 
orders  have  been  strictly  complied  with;  and  if  they  have  not, 
he  should  not  pass  over  the  neglect,  or  it  will  surely  be  repeated. 

As  this  disease  advances  rapidly  to  a  fatal  termination  when 
unchecked,  as  nothing  can  give  this  check  but  the  most  prompt 
application  of  suitable  remedies;  and  as  on  the  extent  and  force 
of  these  remedies  their  success  mainly  depends,  especially  on  the 
proper  quantity  of  blood  to  be  drawn  ;  the  physician  should  per- 
form this  operation  himself,  or  be  present  when  it  is  performed, 
that  he  may  be  satisfied  that  his  intentions  are  properly  fulfilled. 
The  blood  should  be  carefully  preserved,  that  its  quality  may, 
in  some  measure,  serve  as  a  guide  for  the  subsequent  use  of  the 
lancet. 

But  let  us  caution  the  young  practitioner  against  being  deterred 
from  a  repetition  of  this  operation,  if  the  symptoms  continue  ur- 
gent, because  the  blood  may  not  manifest  the  common  signs  of 
inflammation,  for  the  general  symptoms  of  the  disease  will  be  a 
better  guide  than  any  appearance  the  blood 'may  assume. 

When  the  blood  has  been  abstracted,  let  him  order  purgative 
medicines  immediately,  and  this  may  be  in  any  manner  he  shall 
think  most  proper ;  let  him  prescribe  minutely  the  regimen  of  his 
patient,  which  must  be  most  strictly  antiphlogistic.  But  let  us, 
however,  be  exactly  understood  what  we  mean  by  antiphlogistic 


PUERPERAL    FEVER.  423 

regimen ;  and,  as  this  will  refer  to  a  variety  of  particulars,  we 
shall  consider  them  in  detail. 

First.  The  air  of  the  room  should  be  frequently  changed  by  a 
veil-conducted  and  careful  ventilation;  its  temperature  should 
never  exceed  sixty  degrees;  but  it  may  sometimes  be  lower, 
when  a  lower  can  be  commanded.  Its  purity  should  be  preserved 
by  removing  all  offensive  substances  from  the  room  as  quickly  as 
possible,  when  they  are  tangible;  but,  if  they  emanate  from  the 
patient  herself,  the  cause  should  be  diminished  or  destroyed 
whenever  practicable.  The  lochia,  (when  not  arrested,)  are 
sometimes  very  offensive:  when  this  is  the  case,  the  vulva  should 
be  washed  several  times  a  day  with  warm  water ;  the  cloths  often 
changed ;  and  one  constantly  wet  with  the  pyroligneous  acid  and 
water,  should  be  kept  near  the  parts ;  or  if  this  cannot  be  com- 
manded, powdered  lime  should  be  placed  under  the  bed-clothes, 
and  in  various  parts  of  the  room. 

No  curtains  or  other  obstructions  to  the  passage  of  the  air 
should  be  permitted  to  surround  the  bed ;  and  the  doors  and 
windows,  if  at  a  proper  season,  or  in  a  proper  state  of  atmo- 
sphere, should  be  frequently  or  constantly  open.  The  air  should 
not  be  contaminated  by  unnecessary  breaths ;  company,  noise, 
and  light,  should  be  excluded.  The  air  should  not  be  loaded 
with  unpleasant  vapours  or  smokes,  under  the  pretext  of  purify- 
ing it ;  for  every  kind  of  combustion  is  injurious. 

Secondly.  The  diet  should  be  made  to  conform  most  strictly 
to  the  indications  to  be  fulfilled ;  namely,  the  reduction  of  the 
quantity  of  blood,  and  the  action  of  the  blood  vessels;  food, 
therefore,  containing  much  nourishment,  or  any  stimulus,  should 
be  carefully  withheld ;  it  should  be  restricted  to  toast  water,  thin 
barley  water,  molasses  and  water,  thin  rennet-whey,  balm  tea, 
lemonade,  or  gum  Arabic  water. 

Every  shape  and  form  of  animal  substance  should  be  peremp- 
torily forbidden — no  chicken  water  or  beef  tea  should  approach 
the  lips  of  a  fever  patient ;  and  none  should  more  particularly  be 
forbidden  it  than  the  one  labouring  under  puerperal  fever.  We 
are  persuaded  much  mischief  is  created  or  perpetuated  by  a 
want  of  attention  to  this  circumstance ;  and  it  was  not  without 
surprise,  indeed,  we  might  say,  astonishment,  that  we  saw  enu- 
merated in  the  list  of  antiphlogistic  articles  in  the  treatises  of 
Hey  and  Armstrong  "chicken  water,"  than  which,  few  things,  in 
our  opinion,  can  be  more  improper. 

Thirdly.  The  bed,  bed-clothes,  body  linen,  and  every  other 
article  which  may  surround  the  woman,  should  be  changed,  aired, 
or  washed,  (as  their  natures  may  require,)  as  often  as  possible; 
or  as  may  be  compatible  with  the  circumstances  of  the  patient, 
or  as  a  due  regard  to  not  exposing  her  to  unnecessary  fatigue, 
will  permit. 


424  PHLEGMASIA    DOLENS. 

Fourthly.  That,  as  the  abdomen  is  always  very  tender,  and 
oftentimes  very  much  swollen,  the  weight  of  the  bed  clothes 
should  be  taken  from  it,  by  placing  a  spider,  made  of  sections  of 
a  large  hoop,  tied  together  in  their  centres,  at  right  angles  with 
each  other,  and  so  placed  as  to  suspend  the  clothes,  and  thus 
protect  the  abdomen  from  their  pressure.  And,  as  we  know  from 
experience,  that  the  wetting  of  the  abdominal  surface  frequently, 
by  passing  a  sponge  over  it,  imbued  with  some  volatile  fluid,  as 
camphorated  spirit,  alcohol,  or  spirit  of  turpentine,  is  not  only 
most  grateful,  but  we  have  reason  to  believe  has  been  also  most 
useful,  the  patient  should  be  indulged  in  it. 

Fifthly.  The  greatest  care,  and  the  most  delicate  management 
should  be  observed  in  administering  diet,  drinks,  or  medicine  to 
the  patient,  or  in  attending  to  the  effects  of  the  latter ;  and,  that 
she  be  not  made  to  suffer  unnecessary  fatigue,  by  frequent  rising 
for  these  purposes,  we  would  recommend  the  use  of  the  "sick 
cup "  for  the  first  two;  a  spoon  for  the  second,  and  a  bed-pan  for 
the  last ;  knowing  it  to  be  of  the  utmost  consequence  to  husband 
the  strength,  and  prevent  all  needless  hurry  of  the  circulation. 

Sixthly.  To  permit  the  child  to  be  placed  every  now  and  then 
to  the  breast,  that  by  its  gentle  and  appropriate  stimulation  it 
may  invite  the  secretion  of  the  milk,  if  it  has  not  been  formed ; 
or  to  retain  it,  if  it  has  been  secreted;  provided  this  be  managed 
with  so  much  address .  as  not  to  worry  or  fatigue  the  mother. 
The  sympathy  between  the  mammae  and  the  diseased  parts  is 
obvious,  by  the  effect  produced  on  the  one  by  the  situation  of 
the  other.  We  think  we  have  seen  this  useful. 


CHAPTER  XIX. 

9£;    •!,:-'      .--:-4  'JiM.;  -    •    -M '.MI. >.:.*i-;jr.  ;;!.-»:  r-   *,/   ^afcfji   ^|X&$ 

PHLEGMASIA    DOLENS. 

We  have  retained  the  name  of  phlegmasia  dolens,  (the  phleg- 
masia  alba  dolens  puerperarum  of  White,)  for  a  peculiar  condition 
of  the  lower  limb,  because  its  pathology  is  still  as  unsettled  as  it 
was  in  the  time  of  Mauriceau,  whom  we  believe  was  the  first  that 
gave  any  satisfactory  account  of  it;  for  the  description  left  by 
Rodrigues  &  Castro,  can  scarcely  be  tortured  by  any  partiality 
for  antiquity  into  the  disease  of  which  we  are  about  to  treat, 
though  Dr.  Hull  complacently  inclines  to  the  belief  that  he  was 
acquainted  with  it.  And  we  doubt  whether  the  disease  of  the 
apothecary's  wife,  as  described  by  Wiseman,  was  really  the  dis- 


PHLEGMASIA    DOLENS.  425 

ease  in  question,  as  it  is  but  casually  mentioned  in  his  chapter 
upon  "  Abscesses  and  Corrosive  Ulcers,  arising  from  distempers 
of  the  Womb  in  Child-bed,"  and  what  renders  it  especially  doubt- 
ful is,  that  he  declares  matter  formed  in  various  places. 

There  cannot  be  a  question,  however,  that  Mauriceau  was 
well  acquainted  with  this  disease;  as  his  description  is  still  in 
the  main  a  pretty  faithful  one.  By  this  author,  and  several 
others,  the  disease  was  attributed  to  some  derangement  of  the 
lochia,  which,  when  not  sufficient,  was  thrown  upon  the  large 
nerves  of  the  thigh,  and  thus  created  pain  and  swelling,  &c. 
From  the  time  of  Mauriceau,  to  that  of  Puzos,  the  disease  ap- 
pears to  have  been  familiar  to  a  number  of  practitioners,  as 
Manningham,  Mesnard,  &c.  ,;  »,-,• ' 

It  was,  however,  found  after  a  time,  that  the  appearance  of 
this  disease  did  not  obey  any  particular  state  or  condition  of  the 
lochia;  and  that  it  was  very  commonly  accompanied  by  a  dimi- 
nution or  suppression  of  the  milk.  A  new  hypothesis  was  invented, 
and  it  was  made  to  consist  of  a  metastasis  of  this  fluid.  Puzos, 
with  a  great  show  of  reason,  has  a  prior  claim  to  Levret  for  this 
suggestion ;  as  the  latter  himself  refers  to  the  former's  "Memoires 
sur  les  Depots  Laiteux,"  and  speaks  approvingly  of  them.  These 
great  men  were  followed  by  Astruc,  who  treats  expressly  upon 
this  subject.  Sauvages  fully  adopted  these  notions  in  his  noso- 
logy, and  treated  of  them  under  different  genera  and  species. 

Van  Swieten,  Lieutaud,  Raulin,  Sell,  &c.,  all  seem  to  have 
acknowledged  the  great  influence  of  the  milk  upon  the  constitu- 
tion, and  each  has  treated  of  its  metastasis. 

Mr.  White,  of  Manchester,  was  the  next  to  invent  a  theory 
of  this  disease ;  he  made  it  consist  of  an  obstruction,  rupture,  or 
a  disordered  condition  of  the  lymphatics,  and  he  was  followed 
in  this  opinion  by  others.  Mr.  Trye  pretty  freely  criticised  the 
opinion  of  Mr.  W.,  and  said,  that  though  he  could  not  discover 
any  grounds  for  supposing  the  trunks  of  the  lymphatics  to  be 
ruptured  in  lab<Jur,  "  yet  he  could  easily  conceive,  that  the  ob- 
struction to  the  return  of  the  lymph  may  commence  in  the  pri- 
mary inflammation  of  a  trunk  or  trunks,  and  that  probably  this 
may  be  the  case  more  frequently  than  he  had  hitherto  discovered 
or  suspected  it  to  be."  Mr.  Trye  was  followed  by  Dr.  Hull, 
in  a  valuable  and  highly  learned  work  upon  this  obscure  and 
debatable  disease.  Dr.  II.  says,  "  The  proximate  cause  consists 
in  an  inflammatory  affection,  producing  suddenly  a  considerable 
effusion  of  serum  and  coagulating  lymph  from  the  exhalants  into 
the  cellular  membrane  of  the  limb."  Dr.  Davis  of  London, 
next  offered  a  new  pathological  view  of  the  proximate  cause  of 
phlegmasia  dolens,  and  makes  it  consist  in  an  inflammation  of 
"  one  or  more  of  the  principal  veins  within  and  in  the  immediate 
neighbourhood  of  the  pelvis,  producing  a  thickening  of  their 


426  PHLEGMASIA    DOLENS. 

coats,  the  formation  of  false  membranes  on  their  internal  surface, 
a  gradual  coagulation  of  their  contents,  and,  occasionally,  a  de- 
structive suppuration  of  their  whole  texture;  in  consequence  of 
•which,  the  diameters  of  the  cavities  of  these  important  vessels 
become  diminished,  sometimes  so  totally  obstructed  as  to  be 
rendered  mechanically  incompetent  to  carry  forward  into  their 
corresponding  trunks  the  venous  blood  brought  to  them  by  their 
inferior  contributory  branches."1^ 

Thus  we  have  five  different  hypotheses  for  phlegmasia  dolens ; 
of  either  of  which  it  would  be  difficult  to  make  a  choice,  if  we 
consulted  their  value,  either  in  relation  to  the  phenomena  this 
disease  presents,  or  to  the  pathological  condition  of  the  parts 
affected,  as  far  as  has  yet  been  revealed  by  dissection.  On 
these  several  opinions  we  shall  pass  a  few  remarks ;  and  be- 
lieving neither  to  be  the  true  proximate  cause,  think  it  right  to 
give  the  arguments  against  each,  that  our  reading  has  supplied 
us  with,  as  well  as  those  that  have  suggested  themselves  to  us 
from  having  attentively  observed  the  phenomena  of  this  painful 
affection  at  the  bed-side. 

The  first  two  opinions,  (namely,  that  phlegmasia  dolens  is 
caused  by  some  derangement  of  the  lochia,  or  from  a  metastasis 
of  the  milk,)  will  scarcely  require  a  remark,  as  subsequent  ob- 
servation has  abundantly  proved  that  neither  has  ever  had  the 
slightest  agency  in  its  production,  either  as  a  remote  or  as  an 
exciting  cause.  And  farther,  were  either  or  both  to  be  admit- 
ted as  contributing  to  this  affection,  the  pathological  condition 
of  the  seat  of  the  disease,  as  caused  by  them,  would  still  remain 
unexplained. 

Mr.  White,  of  Manchester,  must  be  considered  the  first  writer 
who  had  attempted  a  pathological  exposition  of  phlegmasia  do- 
lens, and  much  credit  is  due  to  his  industry  and  learning  upon 
this  subject,  though  we  cannot  yield  to  him  the  merit  of  having 
been  satisfactory  or  perhaps  even  clear.  He  declares  this  dis- 
ease— 

"  Is  owing  to  the  child's  head  pressing  the  vessel  or  vessels 
which  arise  from  the  lower  extremities  against  the  brim  of  the 
pelvis  during  a  labour  pain,  so  as  to  stop  the  progress  of  the 
lymph ;  that  the  number  of  valves  will  effectually  prevent  it  from 
regurgitating,  and  if  the  head  continues  any  time  in  this  situation 
while  the  lymph  is  driven  on  through  the  valves  by  the  peristaltic 
contraction  of  the  coats  of  its  vessels,  by  the  great  exertion  of 
the  muscles,  and  the  strong  vibration  of  the  inguinal  artery, 
though  its  coats,  (the  lymphatics,)  should  be  allowed  to  be 
stronger  than  those  of  the  blood-vessels,  it  must  at  last  burst  and 
shed  its  contents.  When  the  orifice  made  in  the  lymphatic  is 

'  London  Med.  Chir.  Trans.  Vol.  XII.  p.  426. 


PHLEGMASIA    DOLEXS.  427 

heated,  and  the  diameter  of  the  tube  is  contracted,  or  totally 
closed  by  the  cicatrix,  the  lymph  is  retained  in  the  lymphatic 
vessels  and  glands  of  the  limb,  and  the  labia  [labium]  pudendi, 
and  distends  them  to  such  a  degree,  and  so  suddenly;  as  to  occa- 
sion great  pain  and  swelling,  which  always  begin  in  the  part 
next  to  that  in  which  the  obstruction  is  formed,  and  when  the 
obstruction  is  in  part  or  wholly  relieved,  or  the  lymph  has  found 
a  fresh  passage,  the  part  next  to  it  is  consequently  relieved," 
pp.  49,  50. 

He  adds,  "If  the  above  hypothesis  be  true,  the  predisposing 
cause  may,  in  all  probability,  be  a  weakness  in  the  coats  of  the 
lymphatics  in  such  subjects  only  as  have  these  vessels  formed 
into  one  principal  trunk  under  Poupart's  ligament,"  p.  55. 

Objections  to  these  conjectures  of  Mr.  White  will  readily  pre- 
sent themselves;  for  it  supposes  some  obstructing  cause  of  pres- 
sure to  be  absolutely  necessary.  Now,  if  it  be  even  admitted 
that  the  child's  head  affords  this  pressure  at  the  brim  of  the  pel- 
vis in  some  cases,  it  could  not  have  done  so  in  all  the  instances 
in  which  this  disease  has  appeared.  For,  1st,  this  pressure  can- 
not take  place  to  the  necessary  extent  but  in  a  very  few  instances, 
for  it  is  notorious  to  accoucheurs,  that  for  the  most  part,  in  a 
well-formed  pelvis,  the  head  may  be  even  larger  than  it  is  usually 
found,  and  yet  pass  without  difficulty.  2dly.  The  portion  of  the 
brim  of  the  pelvis  at  which,  in  ordinary  circumstances,  this  pres- 
sure is  found  to  exist,  is  not  that  at  which  the  lymphatics  would 
be  subject  to  its  influence  ;  for,  as  a  general  rule,  it  would  be  be- 
hind either  of  the  acetabula.  3dly.  That  no  other  part  save  the 
head  could  effectually  exert  this  pressure ;  yet  it  is  agreed  on  all 
hands,  that  no  position  of  the  child,  yet  discovered,  is  more  effi- 
cient in  its  production  than  another.  4thly.  That  a  pressure  so 
long  continued,  and  so  effectual  "as  to  stop  the  progress  of  the 
lymph,"  and  eventually  to  cause  a  lymphatic  to  burst,  must  ne- 
cessarily produce,  upon  the  intervening  parts,  a  gangrenous  con- 
dition ;  yet  this^s  a  casualty  we  have  never  heard  of.  5thly. 
Several  circumstances  connected  with  the  history  of  this  disease 
would  still  remain  unaccounted  for;  as  the  occurrence  of  the  dis- 
ease in  the  opposite  limb,  and  this  not  simultaneously,  but  after 
a  considerable  interval,  and  not  until  after,  as  a  general  rule, 
the  first  affection  is  yielding;  to  the  pain  and  swelling  first  oc- 
curring in  the  calf  of  the  leg,  as  it  sometimes  does;  for,  if  Mr. 
White's  statement  be  true,  that  "pain  and  swelling  always  be- 
gin in  the  part  next  to  which  the  obstruction  is  formed,"  p.  51, 
the  pain  and  swelling  must  primarily  exist  in  this  part  of  the 
limb ;  therefore  it  is  not  indebted  to  pressure  exerted  on  the  brim 
of  the  pelvis  for  its  existence. 

The  arguments  just  urged  might  appear  sufficient  for  the  pur- 
pose intended  by  them  ;  but  as  several  conclusive  ones  have  been 


428  PHLEGMASIA    DOLENS. 

employed  by  Mr.  Trye  to  the  same  end,  we  think  we  should  not 
be  rendering  justice  to  this  gentleman,  did  we  altogether  omit 
them.  He  observes,  that  "no  experiment  has  shown  that  the 
lymphatics  can  be  torn,  without  doing  equal  violence  to  the  other 
vessels  of  the  part.  That  practical  anatomists  have  ascertained 
that  these  vessels  will  bear  a  weight  of  quicksilver,  equal  in  effect 
to  a  much  greater  force  than  is  required  to  circulate  the  lymph 
towards  the  thoracic  duct.  That  the  force  exerted  by  the  child's 
head  in  its  passage  cannot  exceed  that  of  the  pad  of  a  tourniquet 
on  the  arm  or  thigh.  That  if  the  trunk  of  a  lymphatic  be  com- 
pressed, its  contents  are  forced  inwards  towards  the  thoracic 
duct,  if  no  obstruction  exists :  in  this  case  its  sides  are  squeezed 
together,  and  will  consequently  occupy  so  little  space,  that  it 
cannot  well  be  ruptured  at  the  compressed  part.  If  a  rupture 
then  take  place,  it  must  be  below  the  compressed  part — but  no 
reason  can  be  given  for  this  taking  place  always  in  one  place, 
namely,  within  Poupart's  ligament,  rather  than  in  the  leg  or 
thigh." 

Besides,  we  have  known  two  instances  of  this  complaint  to 
follow  abortions  in  the  early  months ;  and  once  in  a  premature 
delivery  between  the  sixth  and  seventh  month:  in  this  instance 
the  child  had  been  dead  at  least  one  month  previously  to  its  de- 
livery. Again,  my  friend  Dr.  Chapman  informs  me  of  a  violent 
case  having  occurred  in  a  patient  in  our  Alms-house,  labouring 
under  cancer  uteri.  But,  above  all,  it  has  happened  to  the  arm 
of  the  male,  as  recorded  by  Dr.  Ferriar,1  besides  an  instance  of 
the  same  kind  that  fell  under  our  own  notice  in  1788.  A  gen- 
tleman, pretty  far  advanced  in  life,  received  a  severe  contusion 
on  the  point  of  his  shoulder,  by  the  overturning  of  the  mail  coach. 
He,  however,  paid  but  little  attention  to  it,  and  merely  rested 
it  in  a  sling,  as  it  did  not  prevent  his  attention  to  business  for 
several  days ;  but  at  the  end  of  that  time  the  arm  became  very 
painful,  and  swelled  rapidly  ;  considerable  fever  was  excited,  and 
the  gentleman  was  obliged  to  keep  his  bed.  Tffe  control  of  the 
motions  of  the  limb  was  entirely  lost;  and  every  attempt  to 
move  it  was  attended  by  exquisite  torture.  The  character  of 
the  swelling  was  precisely  that  of  the  milk  leg,  to  which  it  was 
compared  at  the  moment  by  my  preceptor — that  is,  he  declared, 
had  the  same  affection  befallen  the  leg  of  a  lying-in  woman,  he 
would  have  called  it  a  milk  leg.  After  a  tedious  but  an  active 
treatment  for  three  months,  symptoms  of  amendment  showed 
themselves;  but  it  required  a  long  time  to  restore  the  limb  to  its 
former  usefulness — indeed,  from  what  we  afterwards  learnt,  it 
never  became  as  strong  as  the  other. 

1  Medical  Histories,  Vol,  III.  p.  92.     By  Dr.  Ferriar. 


PHLEGMASIA    DOLENS.  429 

This  case  is  not  unique :  several  instances  purporting  to  be  of 
this  kind  are  recorded ;  all  of  which,  perhaps,  are  not  entitled  to 
the  distinction.  Dr.  Ferriar's  case  is  not  an  instance,  perhaps, 
of  genuine  phlegraasia  dolens ;  nor  do  we  regard  the  one  related 
by  Littre,  under  the  care  of  Luminer,  to  be  without  exception, 
as  there  was  well-marked  red  inflammation.1  Yet  that  related 
by  Dr.  Heermans  appears  to  have  been  a  genuine  instance  of 
phlegmasia  dolens  in  the  male.3 

Besides,  we  are  informed  that  phlegmasia  dolens  has  happened 
to  women  not  pregnant;  of  this  we  speak  from  the  authority  of 
others ;  for  we  have  just  said  above  that  this  took  place  in  a 
patient  under  the  care  of  Dr.  Chapman,  in  our  Alms-house ;  and 
Dr.  Beck  mentions  a  case  where  it  occurred  in  a  woman  of  fifty- 
two  years  of  age.  And  we  may  add  to  these,  the  observations 
and  cases  related  by  Dr.  Tweedie  in  Edin.  Med.  and  Surg.  Jour. 
Vol.  30,  p.  250.  Dr.  T.  introduces  the  history  of  the  disease  by 
saying,  "It  corresponds  very  much  in  its  character  and  progress 
with  the  puerperal  phlegmasia  dolens,  although,  from  its  resem- 
blance to  the  cedematous  swelling  of  the  lower  extremities,  which 
occasionally  appears  after  cases  of  protracted  fever,  its  real  na- 
ture and  treatment  are  apt  to  be  overlooked. 

"This  disease,  which  I  conceive  to  be  inflammation  of  the 
cellular  tissue  of  the  limbs,  differs,  however,  in  many  particulars. 
For  example,  in  all  the  instances  I  have  seen,  the  swelling  has 
been  confined  to  one  extremity,  making  its  appearance  first 
about  the  upper  part,  extending  gradually  over  the  whole  limb, 
and  being  attended  with  acute  pain.  It  does  not  retain  the  im- 
pression of  the  finger,  as  in  common  oedema,  which  generally 
commences  round  the  ankle  and  foot,  and  seldom  extends  much 
higher. 

"  I  have  treated  several  cases  of  this  affection  within  the  last 
four  years  at  the  London  Fever  Hospital.  All  the  subjects  of  it 
were  females,  two  of  whom  were  under  twenty  years  of  age,  and 
unmarried.  I  have  been  informed,  however,  that  one  case  oc- 
curred in  a  male,  but  I  have  not  been  able  to  trace  the  history 
or  treatment. 

"  It  may  be  remarked,  that  in  all  the  instances  which  came 
under  my  notice,  active  depletion  had  been  employed  in  the 
treatment  of  the  fever,  so  that  the  convalescences  were  rendered 
somewhat  tedious ;  and  the  first  warning  of  the  disease  was  given 
by  symptoms  of  general  excitement,  which  led  me  to  expect 
either  relapse  or  some  visceral  inflammation.  In  a  few  hours, 
however,  the  cause  of  the  general  disturbance  became  more  ap- 
parent, from  the  patient  complaining  of  stiffness  in  one  of  the 

1  Medico-Chirurgical  Review,  for  April,  1829. 
'Dr.  Francis's  Memoir,  p.  9. 


430  PHLEGMASIA   DOLENS. 

lower  extremities,  followed  by  aching  pain  either  about  the  up- 
per and  inner  part  of  the  thigh,  or  in  the  ham,  around  the  knee 
or  calf  of  the  leg;  and  as  rheumatism  is  by  no  means  an  unfre- 
quent  accidental  accompaniment  of  fever  at  certain  seasons, 
the  uneasiness  and  pain  in  the  limb  are,  at  first,  very  apt  to  be 
ascribed  to  this  cause. 

"In  the  course  of  twelve  to  eighteen  hours  the  pain  and  stiff- 
ness increase,  and,  on  the  limb  being  examined,  it  is  found  some- 
what swollen  and  perceptibly  hotter  than  the  opposite ;  but  there 
is  no  redness  of  the  skin,  which,  on  the  contrary,  has  a  smooth, 
white,  shining  appearance,  and  the  cutaneous  veins  are  distended 
with  blood,  and  occasionally  tortuous.  As  the  disease  advances, 
the  swelling  extends  uniformly  over  the  limb  from  the  upper  part 
of  the  thigh  to  the  toes,  and  feels  tense  and  elastic,  but  not  at 
all  diminished  by  the  semiflexed  position  of  the  limb,  which  the 
patient  generally  refers. 

"  I  also  remarked  the  total  inability  to  move  the  limb,  not  so 
much  on  account  of  pain,  as  from  want  of  command  over  the 
voluntary  muscles.  This  peculiarity  has  been  noticed  by  Mr. 
Burns  in  the  puerperal  phlegmasia  dolens. 

"When  active  treatment  has  been  adopted,  the  pain  abates; 
the  swelling  loses  its  elasticity  and  tension,  so  as  to  retain  par- 
tially the  impression  of  the  fingers  about  the  foot  and  ankle,  and 
the  heat  of  the  limb  diminishes,  but  the  power  of  moving  it  con- 
tinues for  a  long  time  considerably  impaired." 

Dr.  Moore,  of  Ipswich,1  makes  a  singular  remark  upon  the 
opinions  of  Mr.  White,  the  force  of  which  we  cannot  perceive, 
though  it  purports  to  overthrow  at  once  his  doctrine.  He  says, 
"In  refutation  of  Mr.  White's  opinion,  I  will  state,  that  in  no 
instance  that  has  come  to  my  knowledge,  has  the  disease  pre- 
ceded parturition."  Now,  how  this  refutes  Mr.  W's.  opinion  we 
cannot  understand:  for,  in  no  instance  does  Mr.  W.  require  that 
parturition  should  always  happen  before  this  disease  can  be  pro- 
duced; and  in  our  humble  opinion,  had  Dr.  Moore  known  an 
instance  of  phlegmasia  dolens  preceding  parturition,2  it  would 
have  told  very  much  more  against  Mr.  W's.  hypothesis,  as  the 
great  agent  in  producing  this  disease,  in  Mr.  White's  opinion, 
would  have  been  wanting;  namely,  pressure  from  the  child's 
head  during  labour.  But  Dr.  M.  should  not  have  attempted  to 
pass  his  want  of  knowledge  of  such  cases  for  more  than  it  is 
worth;  since  many  cases  of  the  kind  alluded  to  may  have 
taken  place  without  his  being  apprized  of  them;  for,  certainly 

'  New  England  Medical  Journal,  Vol.  II.  p.  229. 

12  Puzos  relates  two  instances  of  this  kind ;  one  took  place  at  the  fourth,  am: 
the  other  at  the  seventh  month  of  utero-gestation.  And  we  have  seen  two  in- 
stances in  which  it  followed  premature  delivery. 


PHLEGMASIA    DOLENS.  431 

it  has  happened,  as  stated  above,  that  this  disease  has  occurred 
to  unimpregnated  females.  Now,  if  this  be  so,  we  do  not  see  by 
what  law  of  pregnancy  the  woman  is  secured  against  an  attack. 

By  the  by,  we  may  remark,  that  Dr.  M.  dismisses  the  hypo- 
theses of  Dr.  Trye  and  Dr.  Ferriar  still  more  cavalierly,  and  with 
still  greater  brevity.  Of  the  first  he  says,  "  It  is  mere  supposi- 
tion ;"  of  the  second,  "  In  reply  to  Dr.  Ferriar,  I  will  adduce  the 
fact,  that  phlegmasia  dolens  as  frequently  follows  natural  and 
easy  labour,  as  difficult  and  laborious." 

These  assertions  of  Dr.  Moore,  purporting  to  be  refutations, 
were  to  pave  the  way  for  an  explanation  which  he  immediately 
after  offers,  in  the  following  terms : — 

"After  an  attentive  observation  of  cases,  and  a  careful  exa- 
mination of  the  subject,  I  will  humbly  offer  the  following  expla- 
nation as  the  most  satisfactory  to  me. 

"During  gestation,  the  abdominal  muscles,  their  vessels,  and 
integuments,  are  in  a  state  of  great  preternatural  distention ;  im- 
mediately after  parturition,  when  the  distending  cause  is  removed, 
these  parts  powerfully  contract  in  order  to  regain  their  natural 
dimensions.  If  this  effort  be  unequally  exerted,  if  it  be  suddenly 
excited  by  the  application  of  cold,  if  the  lymphatic  vessels  be 
over-distended  at  the  time,  if  plethora  or  great  debility  subsists 
in  the  vessels  themselves,  an  interruption  and  accumulation  of  the 
fluid  ensues ;  the  great  and  long  accumulation  of  which,  acting 
as  an  extraneous  and  offending  cause,  will  occasion  inflammation. 
In  persons  of  a  plethoric  and  irritable  habit,  inflammation  may 
quickly  supervene;  while,  on  the  other  hand,  in  a  person  of  a 
contrary  habit,  it  may  be  more  tardy  in  its  progress,"  p.  230. 

We  would  now  ask,  if  ever  hypothesis  was  more  heavily  laden 
with  conjecture  and  supposition  than  this — it  has  not  even  the 
merit  of  ingenuity,  much  less  an  imposing  probability,  to  recon- 
cile its  meager  pretensions.  The  initial  postulate  is  not  founded 
in  fact ;  for  we  cannot  look  upon  the  distention  imposed  upon 
"the  abdominal  muscles,  their  vessels,  and  integuments,"  as 
"preternatural,"  since,  in  being  put  upon  the  stretch  by  preg- 
nancy, they  are  but  performing  one  of  the  offices  for  which  they 
were  designed.  His  second  is  no  better  grounded;  for,  after 
parturition  has  removed  the  distention,  the  abdominal  muscles, 
their  vessels,  and  integuments,"  do  not  "powerfully  contract  in 
order  to  regain  their  natural  dimensions;"  for  this  is  performed 
silently  and  gradually,  and  requires  for  its  completion  many 
days.  We  have  just  shown  how  reluctant  Dr.  M.  is  to  permit 
either  Mr.  Trye  or  Dr.  Ferriar,  to  conjecture  or  to  suppose ;  yet, 
he  says  himself,  in  the  attempt  to  make  out  his  explanation,  "  if 
this  effort,"  &c.,  "ijit  be  suddenly,"  &c. ;  "  if  the  lymphatic 
vessels,"  &c. ;  such  and  such  things  will  happen.  That  is,  we 
shall  have  inflammation  from  an  accumulation  of  lymph  in  the 


432  PHLEGMASIA    DOLENS. 

lymphatic  vessels;  and  in  what  essential  point  does  this  "expla- 
nation "  differ  from  that  of  Mr.  White,  or  Mr.  Trye?  In  none, 
that  we  can  see,  if  we  except  the  agent  by  which  the  interruption 
to  the  circulation  of  the  lymph  is  effected — in  one  instance  it  is 
the  head  of  the  child ;  in  the  other  it  is  cold  and  debility. 

We  should  not  have  thought  it  necessary  to  notice  this  "  ex- 
planation" in  an  especial  manner,  had  not  the  doctrine  it  incul- 
cates led  to  a  mischievous  and  reprehensible  plan  of  treatment ; 
for  the  Doctor  observes,  "  In  the  ordinary  mode  of  treatment, 
much  time  is  lost  in  inefficacious  use  of  diuretics ;  and  much  mis- 
chief and  pain  produced  by  the  application  of  blisters,  and  other 
stimulating  remedies."  "From  the  view  here  taken  of  the..sub- 
ject,  I  am  fully  disposed  to  consider  it  as  a  local  disease,  and 
decidedly  recommend  the  early  application  of  a  large  emollient 
poultice,  which,  by  its  relaxing  and  resolving  power,"  (recollect 
the  Doctor's  opinion  of  the  cause  of  the  disease,  is  debility  and 
over-distention,)  "will,  in  a  great  majority  of  cases,"  (has  he 
ever  seen  a  sufficient  number  to  determine  this  important  point? 
the  Doctor  only  mentions  two  cases,  and  neither  of  which  was 
the  disease  in  question,)  "prevent  the  formation  of  a  distressing 
and  tedious  disease.  And  when  it  does  not  produce  this  most 
desirable  effect,  I  should  recommend  its  continuance,  with  an  in- 
tention of  producing  early  suppuration,  which,  I  think,  next  to 
resolution,  the  most  speedy  and  safe  termination  of  the  disease," 
p.  231. 

Was  ever  a  disease  less  understood ;  or  a  more  preposterous 
remedy  ever  proposed !  The  continued  application  of  an  emol- 
lient poultice  is  every  thing  that  is  necessary  for  the  relief  of  a 
inilk  leg. 

We  have  good  grounds  for  believing  Dr.  Moore  had  never 
seen  a  case  of  phlegmasia  dolens,  if  we  take  the  two  cases  he 
details  as  specimens.  In  the  first  case  the  patient  complained  of 
a  pain  in  the  right  hip  and  back ;  rigours  and  watchfulness ;  a 
rigidity  and  soreness  of  the  abdominal  muscles  ;  pain  in  moving 
the  limb ;  the  pulse  a  little  increased,  slight  thirst,  and  perfectly 
clean  tongue.  For  this  state  of  things,  antimonials,  cathartics, 
and  fomentations  were  prescribed.  These  proved  ineffectual; 
bark,  guaiacum,  and'  a  continued  blister  to  the  thigh  were  em- 
ployed. 

"  This  course  evidently  increased  the  local  affection.  The 
upper  part  of  the  thigh,  the  inguinal  glands,  and  right  iliac 
region  became  more  tumefied,  which  gradually  extended  to  the 
hypogastrium  and  labium  pudendi. 

"In  the  early  stages  of  the  swelling  it  appeared  in  ridges  and 
bunches,  occasionally  assuming  a  livid,  and  at  other  times  a  pur- 
ple hue." ' 

It  became  more  uniformly  diffused,  tender,  hotter  than  natu- 


PHLEGMASIA    DOLEXS.  433 

ral;  shining,  but  not  much  discoloured.  The  fever  kept  pace 
with  the  local  affection ;  the  pulse  was  small  and  very  frequent. 
The  swelling  increased.  "With  an  intention  of  rousing  the  ac- 
tion of  the  absorbents,  a  volatile  stimulating  liniment  was  applied, 
and  in  turn  hot  vinegar :  but  these  had  no  better  effect  than  the 
blistering ! ! 

"Digitalis  was  now  administered ;  this  increased  the  debility; 
the  inflammatory  appearances  became  more  evident;  the  pain, 
heat,  soreness,  and  redness  increased,  until  a  discharge  took 
place  from  a  ruptured  lymphatic  in  her  side,  about  an  inch  from 
the  inferior  spinous  process  of  the  ilium,"  p.  228. 

The  second  case  is  still  farther  removed  than  the  first,  in  our 
opinion,  from  a  case  of  phlegmasia  dolens.  This  occurred  in  a 
person  of  robust  constitution:  it  supervened  on  natural  labour. 
On  the  second  day  after  the  delivery,  the  patient  experienced  a 
great  rigidity  of  the  abdominal  muscles,  which  increased  in  ten- 
derness, and  presented  an  appearance  of  "ridges  and  bunches;" 
the  constitutional  symptoms  high ;  these  increased  until  suppu- 
ration took  place  from  an  "opening  a  little  below  the  navel." 

We  have  italicized  such  parts  of  these  histories  as  show,  at 
once,  that  they  were  not  instances  of  phlegmasia  dolens;  and 
also  such  as  have  excited  our  wonder  in  regard  to  the  treatment. 
If  the  case  just  related,  and  others  that  we  shall  have  occasion 
-to  mention  presently,  be  received  as  instances  of  genuine  phleg- 
masia dolens,  the  pathology  of  this  disease  will  remain  unsettled 
to  the  end  of  time. 

We  have  already  cursorily  mentioned  the  opinion  of  Mr.  Trye, 
of  the  proximate  cause  of  phlegmasia  dolens ;  we  shall  now  ex- 
pose it  more  in  detail.  He  says,  p.  70,  "I  have  considered  the 
proximate  cause  of  the  swelling  to  be  seated  in  the  lymphatic 
glands.  I  will  not  contend  that  it  must  be  so  universally,  be- 
cause there  is  a  probability  that  the  original  seat  of  obstruction 
and  inflammation  may,  in  some  instances,  be  in  the  principal 
trunks  of  the  absorbents  within  the  pelvis,  independent  of,  and 
abstracted  from,  the  iliac  glands ;  in  which  ease  the  inflamma- 
tion may  be  continued  along  the  absorbent  vessels  downwards; 
that  is,  towards  the  labia  pudendi,  leg,  &c.,  as  well  as  upwards, 
or  towards  the  thoracic  duct." 

Dr.  Ferriar  is  also  mentioned  as  an  inventor  of  a  theory  for 
phlegmasia  dolens ;  but  he  does  not  appear  to  be  entitled  to  this 
claim,  since  he  has  only  adopted  the  opinion  of  Mr.  Trye  upon 
this  subject.  And  were  we  even  to  admit  that  he  had  not  seen 
Mr.  T.'s  work,  he  must,  at  least,  have  been  familiar  with  the 
opinions  of  Drs.  Denman  and  Latham.  The  lectures  of  the  for- 
mer he  most  probably  attended. 

We  shall  make  no  observations  upon  the  opinions  of  Mr.  Trye 
and  Dr.  Ferriar,  until  we  have  noticed  the  hypothesis  of  Dr, 
28 


PHLEGMASIA    DOLENS. 

Hull,  which  we  shall  now  give  in  his  own  words.  He  states  that 
"  from  an  attentive  consideration  of  the  whole  of  the  phenomena 
observable  in  this  disease,  and  of  its  remote  causes  and  cure,  no 
doubt  remains  in  my  mind,  that  the  proximate  cause  consists  in 
an  inflammatory  affection,  producing  suddenly  a  considerable 
effusion  of  serum  and  coagulating  lymph  from  the  exhalants  into 
the  cellular  membrane  of.  the  limb."  "The  seat  of  the  inflam- 
mation I  believe  to  be  in  the  muscles,  cellular  membrane,  and 
inferior  surface  of  the  cutis.  In  some  cases,  perhaps,  the  in- 
flammation may  be  communicated  from  these  parts  to  the  large 
blood  vessels,  nerves,  and  lymphatic  vessels,  and  glands  embedded 
in  them." 

We  have  united  the  hypotheses  of  Mr.  Trye,  Dr.  Ferriar  and 
Dr.  Hull,  because  they  are  essentially  one  and  the  same :  namely, 
that  the  proximate  cause  is  an  inflammation  of  the  lymphatics 
and  glands  of  the  groin;  though,  as  a  whole,  Dr.  Hull  assumes 
a  much  broader  ground;  so  much  so,  indeed,  that  Dr.  Davis 
styles  it,  with  much  point,  "a  capacious  theory." 

The  objections  which  present  themselves  to  these  explanations 
are,  first,  their  incompatibility  with  one  especial  phenomenon  of 
the  disease,  namely,  the  shining  white  appearance  of  the  limb 
throughout  the  whole  course  of  the  disease ;  and  this  so  noto- 
riously so,  as  to  have  it  as  one  of  its  genuine  characters.  In  all 
instances  of  inflammation  of  either  muscles,  skin,  lymphatics,1  or 
blood  vessels,  redness  is  a  never-failing  attendant,  as  is  well 
known  to  all  who  are  familiar  with  this  disease.  Yet  this  does 
not  happen  in  phlegmasia  dolens,  notwithstanding  the  numerous 
tissues  Dr.  Hull  involves  in  the  mischief.  2d.  That  if  all  these 
tissues  were  in  a  state  of  inflammation,  this  inflammation  would 
manifest  itself  by  the  ordinary  phenomena  of  this  affection : — 
namely,  heat,  redness,  swelling,  pain  ;  yet  we  find  redness  always 
wanting  in  phlegmasia  dolens,  when  this  disease  is  pure  and 
uncomplicated.  If  muscle  be  inflamed,  redness  is  sure  to  be 
present ;  if  the  skin,  the  same  thing  occurs  ;  if  the  trunks  of  lym- 
phatics (absorbents)  be  the  seat,  we  have  frequent  opportunities 
to  witness  that  they  become  red;  and  when  the  lymphatic  glands 
are  in  this  condition,  redness  notoriously  attends.  And  though 
Dr.  Hull  does  not  suppose  that  all  these  parts  are  simultaneously 
affected,  but  successively,  yet  it  alters  not  the  fact  that  in  phleg- 

1  In  the  time  of  Dr.  Hull,  Ihe  term  "  lymphatics"  was  understood  to  mean  the 
lymphatic  absorbents;  the  researches  of  Bichat  had  not  then  made  it  necessary 
to  distinguish  this  set  of  vessels  and  those  whose  office  it  is  to  convey  the  lymph, 
being  either  the  termination  of  arteries,  or  the  beginnings  of  veins.  And  we  be;; 
the  reader  to  keep  in  mind,  that  where  "  lymphatics"  are  mentioned  in  the  quo- 
tations of  Mr.  White,  Mr.  Trye,  Drs.  Hull,  Ferriar,  or  Moore,  that  the  lympha- 
tic absorbents  are  to  be  understood. 


PHLEGMASIA   DOLENS.  435 

raasia  dolens  redness  is  always  absent  during  the  whole  course 
of  the  disease. 

3d.  Besides,  this  progressive  extension  of  inflammation  cannot 
well  be  sustained,  as  the  rapidity  of  the  disease  is  such,  some- 
times, as  to  involve  the  whole  limb  in  the  course  of  a  very  few 
hours;  whereas,  the  transmission  of  inflammation  by  contact  even, 
is  sure  to  be  much  slower ;  yet  it  would  not  fail  to  betray  its  pro- 
gress by  all  the  common  phenomena  of  inflammation,  were  it  to 
exist  in  such  parts. 

4th.  When  the  lymphatic  glands  become  inflamed  by  the  ab- 
sorption of  some  acrid  substance  or  specific  poison,  the  venereal 
poison  for  instance,  they  not  only  become  red  themselves,  but 
the  lymphatics  even  that  convey  the  poison,  can  be  distinctly 
traced  in  their  course,  by  the  vivid  red  that  marks  their  inflamed 
coats. 

5th.  The  ordinary  inflammation  of  the  several  parts  declared 
to  be  involved  in  phlegmasia  dolens,  moreover,  do  not  thus  sud- 
denly effuse  serum :  of  this,  proofs  present  themselves  every  day 
in  the  usual  progress  of  inflammation,  as  in  rheumatism,  wounds, 
contusions,  the  insertion  of  poisons,  &c. 

6th.  When  the  lymphatics  are  inflamed,  together  with  their 
glands,  it  is  acknowledged  by  Dr.  Ferriar  himself,  that  "the  ves- 
sel can  be  distinctly  traced  in  its  course  by  its  hardness  and  en- 
largement, and  frequently  by  a  slight  inflammation  of  the  super- 
incumbent skin,  forming  a  red  or  purple  streaky  and  extending 
with  the  affection  of  the  vessel."  * 

7th.  We  do  not  agree  with  Dr.  Ferriar  in  the  assertion,  that 
"the  violent  pressure  on  the  internal  iliacs,  and  the  accompany- 
ing veins  and  nerves,  which  takes  place  during  delivery,  must 
undoubtedly  be  considered  as  a  powerful  occasional  cause  of  lym- 
phatic inflammation,"  p.  120.  Now,  if  this  were  true,  phlegmasia 
dolens  would  be  of  more  frequent  occurrence  than  it  is ;  since 
this  pressure  is  common  to  many  labours,  yet  the  disease  in  ques- 
tion is  one  of  very  rare  occurrence. 

8th.  Because,  in  phlegmasia  dolens,  one  of  its  inseparable  cha- 
racters is  the  exquisite  sensibility  of  the  whole  limb  ;  so  much  so, 
in  most  instances,  that  the  patient  cannot  bear  the  slightest  pres-. 
sure,  or  the  slightest  motion ;  yet  Dr.  Ferriar  informs  us  that "  the 
pain  in  lymphatic  inflammation  is  referred  to  the  enlarged  glands, 
and  is  not  remarkably  increased  by  motion:  there  is  more  stiffness 
than  actual  pain  in  the  whole  limb,"  p.  102. 

9th.  Because,  in  the  twelve  or  fourteen  cases  of  exquisitely 
formed  phlegmasia  dolens,  that  we  have  seen,  we  never  were 
able  to  trace  the  "inflamed  lymphatics,"  or  to  feel  the  "enlarged 
conglobate  glands;"  yet  both  of  these  circumstances  are  de- 

'  Med.  Hist.  Vol.  III.  p.  95. 


436  PIILEGMASIA   DOLENS. 

clared  to  be  constantly  present,  by  those  who  espouse  the  patho- 
logy under  consideration.1 

10th.  Because  Dr.  F.  furnishes  a  case  himself,  which  dis- 
proves his  own  explanation,  viz.  "  Jane  Waters,  aged  twenty- 
five,  was  delivered  by  an  accoucheur  of  her  second  child,  Dec. 
26th,  1797,  after  being  four  days  in  labour.  During  delivery 
she  lay  upon  her  left  side.  December  27th,  she  was  affected 
with  pain  and  swelling  of  the  left  knee,  which  descended  to  the 
leg  and  foot  of  the  same  side.  On  the  28th  of  December  the 
swelling  began  to  rise  from  the  left  knee  and  to  affect  the  thigh. 
It  extended  up  to  the  left  groin  and  labia  pudendi.  I  saw  her  for 
the  first  time  on  the  3d  of  January,  1798.  I  found  the  swelling 
tense,  uniform,  not  discoloured ;  that  there  was  a  great  sensation 
of  rigidity  in  the  limb,  and  that  it  was  extremely  painful  on  being 
touched  or  moved.  She  felt  exquisite  pain  in  the  ham,  where  I 
could  perceive  the  lymphatics  a  little  enlarged.  The  glands  of 
the  groin  were  not  affected,"  p.  127. 

In  this  case  there  was  an  exquisitely  formed  phlegmasia  tlolens : 
for  it  was  attended  by  all  the  essential  characters  of  the  disease ; 
the  limb  was  exquisitely  tender  to  the  touch;  the  swelling  was 
uniform  and  elastic;  it  was  not  discoloured;  the  glands  of  the 
groin  were  not  affected,  and  the  lymphatics  in  the  ham  could  be 
perceived  to  be  a  "a  little  enlarged."  Here  then  was  a  case  of 
genuine  milk  leg,  without  inflamed  "lymphatics"  or  "conglo- 
batfe  glands."  We  think  we  have  said  enough  to  prove  that  this 
pathology  is  not  well  founded ;  and  that  if  inflamed  lymphatics, 
or  enlarged  glands  be  present,  that  they  are  the  consequences, 
and  not  causes  of  the  disease  called  phlegmasia  dolens. 

The  next  hypothesis  in  order,  and  it  is  the  last  with  which  we 
are  acquainted,  is  one  of  late  date ;  it  is  by  Dr.  David  Davis,  a 
teacher  and  practitioner  of  considerable  celebrity  in  London. 

Dr.  Davis  attempts  to  prove  that  phlegmasia  dolens  is  the  con- 
sequence of  an  inflammation  of  one  or  more  large  veins;  ending 
in  the  production  of  an  extraneous  membrane,  or  other  obstruc- 
tions, within  their  cavities;  and  thus  offering  remorae  to  the  re- 
turning blood  from  the  extremity. 

This  view  of  the  subject,  from  its  supposed  truth,  has  gained 
much  more  notoriety  than  can  be  sustained  by  facts,  though  sup- 
ported by  the  powerful  aid  of  Velpeau;  and  we  may  add,  that 
of  Bouillaud  and  Ribes.  When  we  say  this,  we  would  not  wish 
to  be  understood  as  implying  the  slightest  disbelief  of  the  truth  of 

1  Dr.  Hull  declares  the  same  inability:  he  says,  "  I  have  never  met  with  either 
enlargement  or  inflammation  of  the  lymphatics  in  any  stage  of  the  complaint;  I 
am,  therefore,  convinced  that  this  is  a  rare  occurrence,  and  by  no  means  essential 
to  the  disease." — Essay  on  Phlegmaaia  Dolens,  p.  116.  It  will,  therefore,  be  per- 
ceived, that  our  observations  apply  to  Dr.  Hull  only,  as  far  as  he  admits  the  lym- 
phatics to  be  involved. 


PHLEGMASIA    DOLENS. 


437 


Dr.  Davis's  statement;  on  the  contrary,  we  are  fully  persuaded 
that  neither  he,  nor  the  gentlemen  who,  both  directly  and  indi- 
rectly, support  his  doctrine,  have  set  down  nothing  that  they  did 
not  see  —  the  only  question  then  is,  were  the  dissections  of  these 
gentlemen  cases  of  phlegmasia  dolens  ?  this  is  the  point  at  issue 
—  whether  phlebitis  and  phlegmasia  dolens  are  identical;  or,  in 
other  words,  are  the  cases  related  as  cases  of  the  latter,  any  other 
than  instances  of  the  former? 

Before  we  proceed  farther  in  the  examination  of  this  question, 
it  will  be  proper  to  determine  the  absolute  character  of  phlegma- 
sia dolens,  from  the  best  accredited  practitioners;  for  to  them 
alone  should  the  appeal  be  made.  And,  perhaps,  one  of  the  older 
writers  of  this  kind  will  be  the  safest  guide  upon  this  occasion. 
Callisen  has  summed  up  the  characters  of  this  disease  most  hap- 
pily in  a  very  few  words,  making  allowance  for  the  introduction 
of  one  of  its  supposed  causes  in  his  time,  namely,  a  metastasis  of 
milk.  "  (Edema  puerperarum,  aliis  lacteum  est  tumeur  elasticus, 
albescens,  renitens,  calidus,  dolens,  foveam  impressi  digiti  haud 
retinens,  puerperis  haud  infrequenter,  gravidis  rarissime  infes- 
t«s."  He  has,  however,  omitted  a  very  material  feature  of  the 
disease,  namely,  fever;  for  as  far  as  we  have  seen,  this  condition 
of  the  system  has  always  been  present,  and  sometimes  to  an 
alarming  degree. 

Th-e  essential  characters  then  of  phlegmasia  dolens  may  briefly 
fee  stated  to  consist  of  the  following  strongly  marked  characters. 
1st.  Fever,  always,  to  a  greater  or  less  degree.  2d.  Pain  gene- 
rally commencing  in  the  hip,  groin,  and  sometimes  the  back. 
3d.  Swelling  commencing  at  the  seat  of  pain,  and  proceeding 
with  more  or  less  rapidity  down  the  whole  limb.  4th.  The  swell- 
ing elastic,  not  retaining  the  impression  of  the  finger.  5th.  The 
whole  swollen  part  white,  even  more  so  than  natural,  in  some 
instances,  but  never  red  when  uncomplicated.  6th.  The  whole 
limb  exquisitely  sensible  to  the  touch.  7th.  Total  inability  to 
move  the  limb,  and  action  always  creating  great  suffering.  8th. 
The  temperature  of  the  whole  affected  part  much  above  the  na- 
tural temperature.  9th.  The  labium  pudendi  of  the  diseased  side 
almost  always  participates  in  the  swelling,  but  never  extending 
to  the  other  labium,  unless  the  other  limb  be  also  affected.  10th. 
After  the  first  leg  begins  to  improve,  or  is,  perhaps,  nearly  well, 
the  opposite  leg  runs  through  a  similar  course,  and  sometimes 
with  an  aggravation  of  symptoms,  llth.  That  the  limb  thus  af- 
fected, rarely  suppurates.  12th.  That  this  disease  is  rarely  at- 
tended by  danger.  13th.  That  after  the  more  violent  stage  of 
inflammation  is  abated,  which  generally  happens,  under  proper 
treatment,  about  the  sixth  or  eighth  day,  that  the  swelling  abates 
its  elastic  character,  and  takes  on  that  of  a  common  oedema. 
14th.  The  milk  usually  diminishes,  and  sometimes  disappears. 


438  PHLEGMASIA    DOLENS. 


We  have  been  thus  particular,  yet  we  trust,  strictly  faithful, 
in  enumerating  the  essential  characters  of  phlegmasia  dolens, 
that  the  coincidences  and  discrepancies  between  it  and  phlebitis, 
may  be  more  readily  subjected  to  comparison. 


Symptoms  and  General  Character  of  Phlebitis. 

In  giving  an  analysis  of  the  symptoms  of  phlebitis,  we  have 
chosen  the  one  condensed  in  the  Medico-Chirurgical  Review,  Vol. 
IV.  p.  509,  from  Recherches  Cliniques  pour  servir  a  1'Histoire  de 
la  Phlebite;  par  M.  J.  Bouillaud,  M.  D.  Revue  Med.  Avril  et 
Juin,  1825 ;  and  from  Expose  succinct  des  Recherches  faites  sur 
la  Phlebite ;  par  M.  F.  Ribes,  M.  D.  Revue  M6d.  Juillet,  1825. 
We  have  chosen  these  in  preference  to  other  authorities,  because 
they  are  the  latest  who  have  written  on  this  subject,  though  we 
have  no  evidence  that  they  consider  phlebitis  identical  with 
phlegmasia  dolens.  We  shall  give  the  English  version,  as  con- 
tained in  the  above  named  Review.  First  of  Dr.  Bouillaud. 

"Symptoms. — 1.  The  symptoms  of  inflammation  in  the  trunk 
of  a  superficial  or  external  vein  are  easily  recognised.  The  mem- 
ber swells,  becomes  hot,  painful,  or  is  even  the  seat  of  phlegmo- 
nous  erysipelas.  The  vessel  itself feeh  tense,  hard,  knotty,  or  like 
a  cord.  Abscesses  not  unfrequently  form  in  the  course  of  the  vein.1 
The  pain,  our  author  thinks,  is  more  dependent  on  an  affection  of 
the  neighbouring  nerves,  than  on  inflammation  of  the  vein  itself. 
(Edema  of  the  limbs  is  a  very  common  attendant  on  phlebitis  of 
one  or  more  of  the  principal  veins,  and  evidently  arises  from  the 
mechanical  obstruction  to  the  return  of  the  blood — the  veins 
being  now  acknowledged  to  be  the  principal  conductors  of  the 
serous  exhalations,  (see  note  to  page  434,)  that  takes  place  in  the 
cellular  tissue.  Such  are  the  signs  of  local  phlebitis. 

2,  When  the  inflammation  extends  to  the  whole  or  to  a  great 
portion  of  that  vast  membrane  which  lines  the  internal  surface 
of  the  venous  system,  we  constantly  find  that  a  violent  fever  is 
lighted  up.  Among  many  of  our  patients,  the  fever  presented  all 

1  It  seems,  from  late  observations,  that  there  is  a  marked  difference  in  the  pa- 
thological conditions  of  the  internal  coats  of  the  arteries,  and  that  of  the  veins:  in 
the  former,  the  adhesive  form  of  inflammation  is  almost  sure  to  occur ;  while  in 
the  latter,  the  suppurative  is  very  certain  to  take  place.  This  latter  circumstance 
has  been  frequently  observed  in  the  veins  of  the  brain,  and  in  those  of  the  uterus. 
Dr.  Clarke  observed  this  condition  of  the  uterine  veins  in  women  who  he  declared 
had  died  of  puerperal  fever;  but,  most  probably,  it  was  from  hysteritis;  and  Dr. 
Abercrombie  andM.  Gendrin  saw  marks  of  a  similar  kind  in  the  venous  tubes  of 
the  brain.  It  must,  however,  be  admitted  that  the  internal  coats  of  the  veins 
have  yielded  lymph  when  inflamed,  and  obliteration  has  followed,  as  in  the  arte- 
ries. Dr.  Bail  lie  relates  a  case  in  which  the  lower  cava,  from  the  emulgent  veins 
to  the  entrance  of  the  vena  cavcE  hepatica,  was  obliterated,  as  he  believed  to  have 
been  produced  by  the  effusion  of  lymph  and  consequent  adhesion. 


PHLEGMASIA   DOLENS.  439 

those  characters  which  are  attributed  to  what  are  called  putrid 
adynamic  or  typhoid  fevers ;  and  indeed  the  term  putrid  is  per- 
fectly applicable,  since  after,  nay  before  death,  there  are  une- 
quivocal signs  of  decomposition,  or  a  kind  of  putrid  fermenta- 
tion of  the  fluids." 

Second.  M.  Ribes  says,  "  The  veins  are  very  frequently  in- 
flamed, and  this  affection  is  a  very  dangerous  one."  (Yet  phleg- 
masia  dolens  is  a  rare  disease,  and  is  very  seldom  dangerous.) 
"In  incipient  phlebitis,  the  patient  experiences  a  slight  pain  in 
the  track  of  the  veins  affected.  These  vessels  swell  and  become 
prominent,  presenting  a  light  bluish  colour,  and  subsequently  a 
brownish  pale  hue.  The  circulation  ceases  in  the  vessel,  and  the 
blood  becomes  more  or  less  decomposed.  If  the  circulation 
should  be  re-established,  the  contents  of  the  vein  are  carried  into 
the  current  of  the  circulation,  and  dangerous  consequences  may 
ensue,"  p.  512.  "Phlebitis  is  a  serious  malady,  and  is  often 
quickly  mortal."  Ibid. 

We  have  thus  brought  into  opposition  the  characteristic  symp- 
toms of  phlegmasia  .dolens  and  phlebitis,  which  we  now  submit 
to  the  reader's  candour  to  determine  the  strength  of  their  analogy; 
or  rather,  how  far  they  have  a  right  to  be  considered  as  absolute 
identity.  Let  him  run  his  eye  over  such  parts  of  the  description 
and  consequences  of  phlebitis  as  are  emphasized,  and  compare 
them  with  the  general  history  of  phlegmasia  dolens,  and  he  will 
at  once  perceive,  we  are  certain,  their  discrepancies,  and  deter- 
mine their  entire  want  of  sameness. 

But  lest  it  be  thought  that  we  have  drawn  our  conclusions 
from  premises  not  attempted  to  be  sustained  by  Dr.  Davis,  we 
will  produce  in  a  very  short  compass  all  the  symptoms  detailed 
in  his  histories,  that  he  may  speak  for  himself. 

"  CASE  I. — Caroline  Dunn,  aet.  21 ;  weak  constitution,  delivered 
on  the  7th  of  February ;  severe  labour ;  some  hemorrhage  after 
delivery;  placenta  removed  artificially.  8th.  Pulse  90;  tongue 
white  and  moist ;  no  pain  in  the  abdomen  from  pressure ;  sore- 
ness in  vagina.  On  the  13th,  slight  fever ;  pulse  full  and  quick ; 
costive ;  tongue  white  and  dry ;  the  labia  pudendi  inflamed  and 
cedematous;  some  headach;  respiration  difficult;  discharge  from 
vagina  resembling  cream.  17th,  better ;  21st,  much  better ; 
22d,  still  better;  26th,  worse;  leg  and  thigh  much  swollen;  pain 
in  the  groin ;  no  signs  of  inflammation ;  no  pitting  on  pressure ; 
28th,  no  better ;  leg  pitted  on  pressure ;  March  3d,  total  insensi- 
bility; limb  equally  swollen;  4th,  died." 

We  shall  introduce  a  part  of  the  dissection  as  performed  by 
Mr.  Lawrence,  "which  is  a  sufficient  guarantee  for  its  correct- 
ness."1 

1  Med.  Chir.  Review,  p.  381. 


440  PHLEGMASIA  DOLENS. 

Dissection. — "  The  left  lower  extremity  presented  a  uniform 
cedematous  enlargement,  without  any  external  discoloration, 
from  the  hip  to  the  foot.  This  was  found,  on  farther  examina- 
tion, to  proceed  from  the  ordinary  anasarcous  effusion  into  the 
cellular  membrane."  The  inguinal  glands  a  little  enlarged,  as 
they  usually  are  in  a  dropsical  limh,  but  without  any  sign  of  in- 
flammation. The  femoral,  external  iliac,  common  iliac,  firmly 
plugged,  apparently  by  a  coagulation  of  blood.  The  other  veins 
thickened,  except  the  saphena  and  branches,  which  were  healthy. 
The  substances  occupying  the  cavities  of  the  vein  were  the  pro- 
duct of  inflammation. 

We  cannot  do  better  than  present  the  observations  on  this 
case  contained  in  a  review  of  Dr.  Davis's  work  on  phlegmasia 
dolens. 

"We  take  the  liberty  of  differing  from  Dr.  D.  on  the  identity 
of  the  case  described  with  that  of  real  phlegmasia  dolens.  We 
ground  our  first  doubt  on  the  fatal  issue  of  the  case,  which  is 
contrary  to  the  general  experience  of  the  profession  hitherto ;  for 
it  must  be  recollected  that  Zinn's  patient  died  of  asthma,  and  not 
of  phlegmasia  dolens.  If,  then,  there  are  very  few  cases  on  re- 
cord, where  phlegmasia  dolens  in  itself  proved  fatal,  we  have  at 
least  grounds  for  supposing,  (we  do  not  say  it  amounts  to  proof,) 
either  that  Dr.  Davis's  case  was  not  phlegmasia  dolens,  or  that 
its  proximate  cause  was  different  from  the  proximate  cause  of 
phlegmasia  dolens  in  general."1  The  reviewer  asks,  in  a  note, 
"Is  it  likely  that  so  serious,  and  generally  so  fatal  a  disease  as 
an  inflammation  of  the  internal  coat  of  veins  under  other  circum- 
stances, should  be  almost  invariably  devoid  of  danger  in  phleg- 
masia dolens?"8 

"Our  main  doubt,  however,"  continues  the  reviewer,  "is 
grounded  on  the  anatomical,  or  rather,  the  pathological  difference 
between  Dr.  Davis's  case  and  those  described  by  authors.  We 
have  Mr.  Lawrence's  authority  that  the  enlargement  of  the  limb 
proceeded  from  ordinary  anasarcous  effusion  into  the  cellular 
substance.  Does  this  state  harmonize  with  the  description  of 
phlegmasia  dolens  as  given  by  authors,  or  as  seen  by  practi- 
tioners ?  It  is  contradistinguished,  by  all  the  writers  we  have 
perused,  from  anasarcous  infiltration,  (and  certainly  from  our 
own  observation  in  at  least  four  or  five  cases,)  by  the  tense, 
or  hard,  or,  at  all  events,  elastic  swelling  of  the  limb — not  pit- 
ting on  pressure,"  p.  382. 

Dr.  Bateman  runs  the  following  parallel  between  the  two  dis- 
eases : — "  The  swelling  is  general  and  equal  over  the  whole  limb ; 
it  is  much  harder  and  firmer  than  in  anasarca,  in  every  stage  of 

1  Med.  Chir.  Rev.  Vol.  V.  No.  18,  p.  382.  a  Ibid. 


PHLEGMASIA    DOLENS.  441 

the  disorder ;  it  is  not  so  cold,  in  any  state  of  the  disease,  as  in 
the  dropsical  swelling,  nor  so  much  diminished  by  the  horizontal 
position ;  neither  does  it  pit  when  pressed  upon  by  the  finger,  nor 
does  any  water  issue  from  it  when  it  is  punctured  by  means  of 
a  lancet."1  "When  these  descriptions  are  compared  with  Mr. 
Lawrence's  dissection,  we  think  every  unprejudiced  mind  will 
agree  with  us,  that  Dr.  Davis's  case  was  of  a  character  wholly 
different  from  genuine  phlegmasia  dolens,"  p.  383. 

"CASE  II. — A  lady  of  a  sanguineous,  irritable  temperament, 
died  suddenly  in  the  midst  of  apparently  high  and  perfect  health, 
on  the  20th  of  September,  1819,  six  weeks  after  confinement. 
She  was  seized  with  peritoneal  inflammation  the  day  after  deli- 
very, which  yielded  to  active  measures.  Ten  days  after  this, 
she  complained  of  deep-seated  pain  in  the  groin,  and  along  the 
great  vessels.  Dr.  D.  found  the  limb  swelled,  and  very  painful, 
but  by  leeches  and  blisters,  this  new  inflammation  was  speedily 
reduced,  and  in  a  week  the  swelling  had  entirely  subsided,  the 
patient  having  recovered  the  perfect  use  of  the  limb.  From  this 
period  she  convalesced  rapidly  and  satisfactorily,  but  died,  as 
above  stated,  in  the  midst  of  apparent  health." 

In  what  possible  respect  can  this  case  be  looked- upon  as  a  case 
of  phlegmasia  dolens  ?  Is  there  a  single  coincidence  of  symptom 
between  the  two  diseases?  The  only  circumstance  on  which 
even  a  remote  analogy  can  be  based,  is  "a  deep-seated  pain  in 
the  groin,"  and  that  "  the  limb  was  considerably  swelled  and  ex- 
quisitely painful."  But  will  such  conditions  of  a  limb  alone, 
constitute  phlegmasia  dolens? 

"CASE  III. — This  is  a  case  communicated  by  Dr.  Davis's 
friend,  Mr.  Oldknow.  A  woman  was  delivered,  by  an  easy  la- 
bour, in  September,  1820.  She  did  well  for  about  three  weeks. 
She  was  then  attacked  by  a  violent  diarrhoea,  for  which  she  took 
astringents.  Fever  continued.  On  the  thirtieth  day  after  de- 
livery the  diarrhosa  returned,  and  'the  left  lower  extremity  be- 
came swollen  and  painful,  with  considerable  increase  of  fever.' 
Four  days  afterwards  she  died,"  p.  435. 

In  this  case  the  only  pretence  for  calling  this  a  case  of  phleg- 
masia dolens,  during  the  life  of  the  patient,  was  the  existence 
"of  swollen  and  painful  lower  extremity;"  and  no  proof  of  its 
having  been  a  case  of  this  kind  is  adduced  by  the  examination 
after  death.  The  whole  attention  of  the  operator  appears  to  have 
been  occupied  in  the  examination  of  the  bloodvessels:  "the 
femoral  vein  and  iliac  veins  were  much  enlarged,  and  contained 
adherent  layers  of  coagulated  blooll.  The  same  appearances,  but 
in  a  lesser  degree,  were  observed  in  the  cava  as  far  as  the  en- 
trance of  the  renal  veins.  The  coats  of  the  veins  were  highly 

1  Rees's  Cyclopedia,  Vol.  2d. 


442  PHLEGMASIA    DOLENS. 

inflamed,  and  intimately  attached  to  the  surrounding  parts.  The 
absorbents  o,nd  glands  were  slightly  enlarged."  These  morbid 
changes  may,  perhaps,  with  propriety,  entitle  this  case  to  stand 
with  those  of  phlebitis;  but  it  has  no  possible  right  to  be  ranked 
with  those  of  phlegmasia  dolens. 

The  sudden  death  of  this  patient,  we  conceive,  will  effectually 
prevent  her  case  from  being  acknowledged  as  one  of  phlegmasia, 
dolens,1  for  we  believe,  from  what  we  have  seen  and  read  of  this 
disease,  that  it  is  the  first  instance,  if  it  be  one,  that  has  termi- 
nated so  suddenly  in  death.  Indeed,  this  termination  is  so  con- 
fessedly rare,  that  phlegmasia  dolens  has  never  been  looked  upon 
as  a  disease  of  danger,2  though  one  for  a  time  of  great  suffering, 
and  almost  always  one  of  tedious  convalescence. 

CASE  IV. — A  lady  of  a  delicate  constitution  and  irritable  habit, 
was  delivered  on  the  2d  of  July,  1821.  She  was  doing  well 
until  the  seventh  day;  on  this  day  she  was  exposed  to  cold,  and 
was  seized  with  a  rigour.  During  the  forming  of  the  hot  stage, 
she  felt  a  pain  in  her  left  side,  which  increased  rapidly,  and  for 
which  she  was  bled  without  much  relief.  She  was  afterwards 
bled,  leeched,  and  blistered.  The  affection  of  the  chest  was  re- 
lieved, but  fever  continued.  In  the  evening  of  the  9th,  "Un- 
equivocal symptoms  of  phlegmasia  dolens  declared  themselves." 
She  died  on  the  23d  of  the  same  month. 

"On  dissection,  there  was  effusion  and  inflammation  in  the 
chest,  '  the  left  lower  extremity  from  the  hip  to  the  toe,  was  con- 
siderably, but  not  greatly  enlarged,  and  there  was  an  evident  en- 
largement of  the  labium  pudendi.'  The  iliac  veins  on  both  sides 
were  unusually  turgid  with  blood.  When  the  left  was  opened, 
it  was  found  to  contain  a  firm  coagulum  of  blood,  not  adherent 
to  the  vessel  at  that  place.  Higher  up,  however,  in  the  common 
iliac  portion,  the  coagulum  was  adherent  to  the  internal  surface 
of  the  vessel.  The  left  internal  iliac  was  greatly  inflamed,  and 
the  diameter  so  much  contracted  as  to  be  almost  impervious. 

"  In  the  above  case,  we  have  to  regret  that  nothing  is  said  of 
the  state  of  the  limb  from  the  9th  of  July,  '  when  the  unequivo- 
cal symptoms  of  phlegmasia  dolens  commenced,'  till  the  patient's 
death.  In  the  dissection,  again,  nothing  is  said  of  the  patholo- 
gical condition  of  the  limb.  The  whole  attention  is  concentrated 
on  the  vessels.  Now  it  ought  to  have  been  Dr.  Davis's  chief  and 
main  object  to  prove,  in  all  these  cases,  that  the  disease  was 

1  It  is  true,  that  in  the  case  related  by  Puzos,  the  patient  died  on  the  fifth  day, 
but  she  appears  rather  to  have  "  died  of  the  doctor,"  than  of  phlegmasia  dolens. 
He  relates  another  that  took  place  in  the  fourth  month  of  pregnancy,  and  which 
proved  fatal  on  the  ninth  day. 

"  Dr.  Francis  relates  a  case,  on  the  authority  of  Dr.  Mann  of  Boston,  in  which 
death  took  place  from  sphacelus,  in  consequence  of  the  limb  being  punctured  with 
a  view  to  draw  off  the  water  supposed  to  be  present. 


PHLEGMASIA    DOLENS.  443 

really  phlegmasia  dolens,  by  an  accurate  description  of  the  symp- 
toms and  state  of  the  limb,  and  then  to  have  traced  the  cause,  if 
he  could.  But  it  is  evident  that  the  first  and  main  object  is  al- 
most totally  neglected — or  where  it  is  adverted  to,  as  in  Mr. 
Lawrence's  dissection,  it  makes  against  the  question — and,  there- 
fore, we  do  not  consider  ourselves  bound  to  subscribe  to  our  au- 
thor's etiology,  without  having  the  necessary  documents  respect- 
ing the  symptoms  and  dissections  of  the  cases."1 

We  cannot,  however,  hesitate  to  believe,  that  the  swelling 
spoken  of  was  produced  by  the  inflammation  and  obstructions 
discovered  by  dissection,  as  Ribes  tells  us  it  is  one  of  the  com- 
mon symptoms  of  phlebitis;  but  we  must  deny  that  that  swelling 
and  the  swelling  attending  phlegmasia  dolens  are  of  one  and  the 
same  kind,  as  this  author  expressly  called  it,  "oedematous." 

From  all  the  facts  adduced  by  Dr.  Davis  in  support  of  his  pa- 
thology of  phlegmasia  dolens,  sufficient  evidence  is  not  afforded 
that  "the  proximate  cause  of  this  disease  is  a  violent  inflamma- 
tion of  one  or  more  of  the  principal  veins  within  and  in  the  im- 
mediate neighbourhood  of  the  pelvis,"  &c.  Nor,  in  our  opinion, 
is  this  pathology  sustained  by  the  cases  related  by  Velpeau,  pur- 
porting to  illustrate  the  cause  of  this  disease,  though  they  coin- 
cide with  the  observations  of  Dr.  Davis. 

Dr.  Velpeau  has  drawn  the  same  conclusion  as  regards  the 
proximate  cause  of  phlegmasia  dolens  as  Dr.  Davis,  though  not 
aware  he  had  been  anticipated  in  this  by  the  latter  gentleman. 
We  will  briefly  relate  his  cases — that  is,  we  will  mention  every 
circumstance  which  may  bear  upon  the  question. 

CASE  I. — Valette,  eighteen  years  old,  had  a  tedious  labour : 
on  the  third  day  she  was  much  affected  by  some  melancholy  ti- 
dings. She  now  laboured  under  an  acute  pneumonic  affection. 
Eleven  days  after  delivery  she  had  chills  and  fever,  pain  in  the 
groin,  hypochondria,  and  left  side  of  the  pelvis.  On  the  forty- 
first  day,  the  left  leg  was  found  to  be  swelled,  with  pain  in  the 
hip  and  groin,  and  ultimately  in  the  whole  limb.  "The  whole 
extremity  cedematous."  Pressure  gives  pain  only  in  the  groin. 
On  the  sixtieth  day  she  died. 

Dissection. — "When  the  left  extremity  was  cut  into,  it  was 
found  much  infiltrated  in  the  cellular  tissue.  The  lymphatic 
glands  of  the  groin  were  much  swelled  and  red, — the  muscles 
small  and  pale," — crural  vein  red  externally,  and  its  cellular  coat 
thickened.  This  was  the  case  in  all  its  deep-seated  branches. 
Purulent  matter  was  found  in  these  veins,  and  pus  in  the  cava, 
and  purulent  deposition  in  other  places.  Can  any  one  recognise 
phlegmasia  dolens  in  the  history  of  this  case,  or  in  the  details  of 
the  dissection  ?  There  was  a  swelled  leg,  it  is  true — but  it  is 

*  Med.  Chir.  Rev.  p.  385. 


444  PHLEGM  ASIA    DOLENS. 

expressly  declared  to  be  "  oedematous,"  and  this  is  the  only  re- 
semblance. 

CASE  II. — Damiens,  thirty-five  years  of  age.  She  had  a  quick 
delivery.  During  the  first  three  days  nothing  remarkable  oc- 
curred. Fourth,  fever,  and  deep-seated  pain  in  the  pelvis.  On 
the  thirteenth  day  the  lower  extremities  are  much  swelled  and 
painful,  especially  the  left.  Fifteenth,  breathing  affected,  diffi- 
culty in  passing  water,  diarrhoea.  Twentieth,  the  lower  extremi- 
ties more  swelled  and  red,  (enfl6es  et  rouges,)  belly  swelled  and 
painful.  Twenty-sixth  day,  died.  In  the  dissection  there  was 
nothing  to  justify  the  opinion  that  this  was  a  case  of  phlegmasia 
dolens :  or  perhaps  that  it  was  a  case  even  of  phlebitis. 

CASE  III. — Has  even  less  claim  to  the  title  assumed  for  it  than 
the  preceding — the  only  possible  circumstance  to  rest  such  an 
opinion  upon  is,  that  "there  were  pains  in  the  upper  and  lower 
extremities — the  latter  beginning  to  show  oedema." 

Such  are  the  kind  of  cases  which  of  late  have  been  foisted 
upon  the  medical  public,  for  instances  of  phlegmasia  dolens ;  than 
which,  nothing  can  be  less  similar.  Dr.  Davis  has  evaded  all 
the  difficulties  that  might  attach  to  a  regular  history  of  the  ap- 
pearances of  the  limb,  by  declaring,  in  some  instances,  that 
"to-day  unequivocal  signs  of  phlegmasia  dolens  appeared:1'  we 
must,  therefore,  take  his  word  for  the  truth  of  the  observation ; 
— not,  however,  that  we  would  insinuate  that  he  would,  in  the 
slightest  degree,  misrepresent  the  appearances  which  led  him  to 
this  conclusion,  but  that  he  was  satisfied  with  symptoms  which 
we  think  did  not  constitute  the  disease.  The  cases  of  Bouillaud 
and  Ribes  are  precisely  of  the  same  character,  as  regards  their 
relation  to  phlegmasia  dolens,  though  they  may  be  looked  upon 
as  instances  of  phlebitis.  But  to  Velpeau  we  cannot  even  ac- 
cord this  acknowledgment. 

We  find  also  a  case  recorded  in  the  Medico-Chirurgical  Re- 
view, for  1825,  Vol.  III.,  new  series,  p.  540,  which  purports  to 
be  a  case  of  phlegmasia  dolens,  that  required  the  amputation  of 
the  leg  in  consequence  of  an  apprehended  sphacelus.  The  only 
circumstance  on  which  the  title  of  the  case  is  founded  is,  that 
"  the  limb  was  NOT  evidently  swelled,  but  there  was  a  good  deal 
of  tenderness  in  and  about  the  ham"  But,  unfortunately  for  Mr. 
Davies,  the  narrator  of  this  case,  he  had  just  before  informed 
us,  that  "  the  limb  became  instantly  paralyzed  from  below  the 
knee  to  the  toes,  by  a  sudden  metastasis  of  excruciating  pain 
from  the  left  loin  and  hip,  which  suddenly  flew  down  to  the  leg 
and  foot."  On  dissecting  the  amputated  limb,  "the  veins  were 
found  completely  distended  with  firmly  coagulated  blood;  their 
coats  were  thickened,  and  their  inner  surfaces  very  much  in- 
flamed. In  consequence  of  which  Mr.  Davies  declares  that  "the 
morbid  appearances  tend  to  confirm  the  truth  of  Dr.  Davis's  views 


PHLEGMASIA    DOLENS.  445 

of  the  pathology  of  phlegmasia  dolens."  To  which  we  might 
perhaps  agree,  if  there  had  been  a  single  symptom  of  this  disease 
present;  or  if  Dr.  Davis  had  proved  that  phlebitis  and  phlegmasia 
dolens  were  one  and  the  same  disease ;  or  even,  if  in  phlegmasia 
dolens,  that  phlebitis  were  constantly  present.  This  latter,  how- 
ever, we  confess,  would  have  been  a  most  difficult  task,  as  the 
rare  fatality  of  phlegmasia  dolens  leaves  but  very  scanty  chances 
to  do  so ;  while  phlebitis  is  very  frequently  fatal.  But  what  will 
be  said  by  the  advocates  of  this  new  doctrine  of  phlegmasia  do- 
lens to  the  observations  of  M.  Tonnell6  upon  puerperal  fever,  and 
in  which  the  subject  of  phlebitis  is  mentioned  as  a  frequent  oc- 
currence ;  and  which  has  a  direct  bearing  upon  the  subject  in 
question ;  and,  we  may  add,  with  a  peculiar  force,  as  his  facts 
were  not  intended  to  be  applied  to  the  use  to  which  we  now  wish 
to  apply  them — namely,  that  of  324  cases  of  puerperal  fever,  there 
were  134  in  which  pus  was  found  in  the  veins  and  lymphatics ; 
yet  even  oedema  was  present  but  in  one  instance ;  and  not  one 
word  is  said  of  phlegmasia  dolens  ?  Could  such  a  state  of  a  limb 
have  been  overlooked  by  apparently  so  careful  an  observer  as 
M.  T.,  had  it  been  present  ?  And  if  uterine  phlebitis  be  the 
cause  of  phlegmasia  dolens,  would  it  not  be  reasonable  to  have 
expected  one  case  of  it,  among  so  many  instances  of  phlebitis? 
And  farther,  that  phlebitis  uniformly  gives  rise  to  a  typhoid  form 
of  fever;  a  circumstance  well  worthy  of  note,  as  no  such  type  of 
fever  has  ever  been  found  to  belong  to  phlegmasia  dolens. 

Having  thus  reviewed  the  several  opinions  which  have  been 
offered  on  the  proximate  cause  of  phlegmasia  dolens,  we  are 
every  way  assured,  that  they  will  appear  to  the  greater  part  of 
medical  practitioners  as  unsatisfactory  as  they  have  to  us;  but 
that  they  unequivocally  prove,  that  this  interesting  subject  of 
pathological  research  remains  still  unsettled.  We  have,  upon  this 
subject,  but  two  suggestions  to  make;  namely — 1st,  be  the  affec- 
tion seated  in  whatever  tissue  it  may,  its  character  is  highly  in- 
flammatory; 2d,  that  in  our  opinion,  this  inflammation  occupies 
exclusively  the  white  lymphatic  vessels  of  the  cellular  membrane 
of  the  several  textures  of  the  limb ;  for  we  are  every  way  satisfied 
that  redness  is  not  essential  to  inflammation,  as  we  have  before 
declared.  We  therefore  agree  in  part  with  Dr.  Hull,  since  he 
admits  among  the  tissues  he  particularizes  as  being  involved  in 
this  disease,  the  cellular  membrane  as  one.  And  in  support  of 
the  opinion  we  have  adopted  respecting  inflammation,  we  think 
we  cannot  do  better  than  employ  his  arguments  against  redness 
being  a  sine,  qua  non  to  its  existence. 

"  Should  it  be  objected  to  this  theory,  that  there  is  no  redness 
of  the  external  surface  of  the  cutis,  my  answer  is,  that  redness, 
though  a  general  attendant  of  inflammation  in  the  human  body, 
does  not  constitute  inflammation,  nor  is  it  a  circumstance  essen- 


446  PHLEOMASIA    DOLENS. 

tially  necessary  to  inflammation.  The  cheek,  in  blushing,  for 
example,  presents  redness  and  increase  of  heat  to  the  eye  and 
touch:  but  there  is  no  pain,  consequently  no  inflammation.  The 
cornea,  on  the  other  hand,  when  we  cannot  trace  a  single  vessel 
carrying  red  blood  beyond  its  margin,  is  frequently  affected  with 
inflammation:  there  is  pain,  heat,  &c.,  and  small  abscesses  or 
ulcers,  or  depositions  of  coagulable  lymph,  commonly  called 
specks  or  pearls,  take  place  in  it.  Animals  which  have  no  red 
blood  in  any  part  of  their  system,  are  not  exempt  from  inflam- 
mation. And  the  less  acute  kinds  of  inflammation  which  take 
place  in  the  membranes  of  the  brain,  the  pleura,  peritoneum, 
tunica  vaginalis,  testes,  &c.,  are  not  always  characterized  by 
an  evident  redness,  especially  when  an  extravasation  of  coagu- 
lating lymph,  or  a  large  effusion  of  serosity  soon  happens  and 
moderates  them,  as  in  peritonitis  conjunctiva,  and  apoplexia 
hydrocephalica  Culleni,  and  the  acute  stages  of  hydrothorax, 
ascites,  and  hydrocele.  Hence,  it  may  happen  that  when  the 
symptoms  of  a  disease  induce  the  attending  physician  to  consider 
it  as  a  phlegmasia,  dissection  may  be  supposed  to  show  that  he 
is  mistaken  as  to  the  nature  of  the  complaint,  if  redness  be  ad- 
mitted as  an  essential  mark,  a  sine  qua  non  of  inflammation. 
Indeed,  this  point  appears  to  be  almost  entirely  given  up  by  late 
pathologists."1 

What  the  exciting  causes  of  this  disease  may  be,  we  are  not 
exactly  prepared  to  say,  as  it  takes  place  in  two  diametrically 
opposite  conditions  of  the  system ;  namely,  that  of  repletion  and 
of  exhaustion.  Thus,  we  have  seen  it  in  two  highly  plethoric 
females ;  in  one  the  labour  was  rapid  and  easy ;  in  the  other  it 
was  rather  tedious,  and  very  painful.  In  several  others  we  have 
witnessed  it  to  follow  severe  and  extensive  uterine  hemorrhages, 
and  were  we  to  decide  from  our  own  experience  as  to  the  fre- 
quency of  its  occurrence  after  any  one  condition  of  the  system, 
we  should  say  it  was  most  apt  to  follow  severe  uterine  losses  of 
blood  than  from  any  other  single  cause. 


Method  of  Cure. 

However  writers  may  disagree  as  regards  the  particular  struc- 
ture occupied  by  this  disease,  they  are  unanimous  with  respect  to 
the  nature  of  it — they  all  maintain  it  to  be  inflammatory.  About 
this  there  can  be  no  mistake,  as  all  its  symptoms  and  habits  de- 
clare this  condition  of  the  tissue  to  be  present.  We  have  fever 
with  a  highly  active  pulse;  a  hot,  dry  skin ;  acute  pain;  and 
swelling,  attended  by  heat  of  the  part;  excessive  soreness  of  the 

1  Hull  on  Phlegmasia  Dolens,  p.  209. 


.      PHLEGMASIA    DOLENS.  447 

limb  to  the  touch ;  great  thirst,  sometimes ;  white  tongue,  &c. ; 
in  a  word,  every  thing  that  betrays  an  active  local  inflammation. 

Blood-letting  and  Leeching. 

The  means  of  cure  consist  in  depletion  from  the  circulating 
system,  both  general  and  local — we  therefore  abstract  blood  from 
the  arm,  to  the  full  extent  the  system  will  bear  at  the  time ;  but 
which  must  be  repeated,  if  the  fever  be  but  little  or  none  abated, 
and  the  pain  be  undiminished.  So  soon  as  the  force  of  the  pulse 
is  diminished,  if  the  fever  continue,  leeches  should  be  applied  to 
the  diseased  limb,  in  such  number  as  shall  secure  the  loss  of  five 
or  six  ounces  of  blood.  Our  practice,  in  the  use  of  leeches,  is  to 
have  them  pretty  much  dispersed  over  the  surface  of  the  limb, 
that  their  bites  may  not  be  too  near  each  other;  as  they  some- 
times leave  troublesome  sores,  when  crowded  together  where  the 
skin  is  much  distended.  The  leeching  may  be  repeated  in  a  day 
or  two,  provided  the  pain,  heat,  and  elastic  feel  of  the  swelling, 
remain  severe  or  unabated.  We,  however,  never  apply  the 
leeches  until  arterial  force  is  weakened  by  bleeding  from  the 
arm ;  as  relief  is  by  no  means  certain  unless  this  has  taken  place. 
In  two  or  three  cases  we  were  obliged  to  repeat  the  bleeding 
six  or  seven  times,  and  the  leeching  two  or  three,  before  the 
disease  yielded. 

Purging,  £c. 

In  aid  of  blood-letting,  we  employ  purging  to  a  liberal  extent, 
during  the  continuance  of  the  active  stage  of  the  disease ;  and, 
for  this  purpose,  we  prefer  the  saline  cathartics ;  especially  when 
combined  with  an  equal  weight  of  calcined  magnesia;  the  follow- 
ing are  the  usual  doses:  f&.  sulph.  magnes.,  magnes.  alb.  ust.  aa. 
3iij.  M.  div.  in  iij.  One  of  these  portions  to  be  given  every 
two  hours,  in  a  wine-glassful  of  sweetened  water  or  lemonade, 
until  they  operate  freely. 

We  have,  also,  found  decided  advantage  in  the  nitrous  anti- 
monial  powders,  until  fever  is  reduced,  or  perspiration  estab- 
lished. The  regimen,  throughout  the  active  stages  of  the  disease, 
is  to  be  strictly  antiphlogistic. 

Topical  Applications. 

Much  injury  is  oftentimes  done  by  the  injudicious  employment 
of  stimulating  embrocations  or  liniments :  this  should  be  peremp- 
torily forbidden.  No  kind  of  application  whatever  should  be 


448  PHLEGMASIA    DOLENS. 

made  to  the  limb  itself  until  after  the  fever  has  abated  and  the 
pulse  is  reduced  by  bleeding;  or  leeching  the  limb.  When  this 
is  effected,  the  vinegar  vapour  bath  may  be  used,  two  or  three 
times  a  day,  with  great  advantage,  but  not  before. 

The  mode  of  employing  this  is  as  follows :  the  limb  should  be 
bared  in  the  bed,  and  the  bed-clothes  be  raised  from  it  by  means 
of  a  common  hoop  from  a  barrel  being  cut  in  two  and  tied  to- 
gether at  right  angles  with  each  other;  this  must  be  made  to 
straddle  the  leg.  Three  bricks  must  be  heated  pretty  hot,  and 
then  plunged  in  vinegar;  after  they  are  loaded  with  the  vinegar, 
they  may  be  folded  in  cloths,  and  one  applied  to  each  side  of  the 
limb,  and  the  other  to  the  foot.  The  bed-clothes  must  now  be 
returned  over  the  spider,  to  keep  in  the  vapour  arising  from  the 
bricks.  This  steaming  should  be  continued  until  the  patient 
complains  of  feeling  weak ;  they  are  then  to  be  removed.  This 
process  is  almost  certain  to  produce  a  copious  perspiration  over 
the  whole  extent  of  the  limb.  Should  this,  however,  not  be 
found  to  be  the  case  upon  examining  the  limb  in  fifteen  or  twenty 
minutes  after  the  application  of  the  bricks,  but  instead,  the  limb 
is  found  to  be  hot  and  dry,  these  articles  should  be  removed,  as 
they  will  not  succeed  if  they  are  even  allowed  to  remain,  as  the 
heat  of  the  limb  is  beyond  the  sweating  point. 

When  this  happens,  we  may  be  certain  that  the  bricks  have 
been  applied  too  early — that  is,  before  arterial  action  was  suffi- 
ciently reduced.  In  this  case,  we  must  renew  the  depleting  re- 
medies, either  general  or  local,  or  both.  On  this  account,  it  is 
always  well  to  examine  the  pulse  carefully  before  we  have  re- 
course to  this  remedy.  But  when  perspiration  is  induced,  the 
patient  is  almost  certain  to  experience  great  relief,  though  for 
the  most  part  but  temporary  at  first ;  it  must,  therefore,  be  re- 
newed whenever  the  pain  becomes  excessive. 


Opium. 

From  pain,  and  that  excessive  for  the  most  part,  being  the  con- 
stant attendant  upon  this  complaint,  it  has  been  thought  too  ge- 
nerally, that  opium,  in  some  form  or  other,  should  be  administered 
— but  this,  in  our  hands,  has  always  been  found  highly  injurious 
in  the  early  and  active  stage  of  phlegmasia  dolens.  It  should, 
therefore,  never  be  given  until  the  system  be  sufficiently  reduced 
to  bear  this  drug  with  advantage.  And  when  it  is  eligible,  the 
best  mode  of  administering  it  is  by  injection.  And,  for  this  pur- 
pose, a  tea-spoonful  of  laudanum,  in  a  gill  of  warm-water,  may 
be  used  as  occasion  may  require.  Or  Dover's  powder  may  be 
used  at  bed-time,  in  the  dose  of  ten  grains,  when  the  system  can 


PHLEGMASIA    DOLEXS.  449 

* 

bear  with  profit  the  stimulus  of  its  opium,  and  especially  when 
the  skin  is  indisposed  to  perspiration. 

As  a  general  rule,  the  system  will  not  bear  the  use  of  opium  as 
long  as  the  swelling  preserves  its  elastic  character,  and  this  is 
generally  from  six  to  eight  days.  Nor  should  any  stimulating 
applications  to  the  limb  be  resorted  to,  until  the  intumescence 
puts  on  the  appearance  of  oedema;  for,  until  this  change  takes 
place,  the  active  inflammatory  stage  has  not  passed  <away. 
About  the  time  above  specified,  (for  we  have  known  it  happen 
earlier  or  be  retarded  later,)  pain,  heat,  fever,  and  swelling,  be- 
gin to  abate,  and  the  patient  is  able  to  support  her  sufferings 
with  less  complaint.  She  can  now,  for  the  most  part,  bear  the 
limb  to  be  moved,  or  its  position  changed,  without  so  much  tor- 
ture, though  still  very  far  from  being  relieved. 


External  Applications. 

We  have  always  made  the  changes  now  spoken  of  the  guide 
for  an  additional  application  to  the  affected  limb ;  (that  is,  when 
there  is  an  abatement  of  the  constitutional  symptoms,  and  the 
swelling  will  retain  the  impression  of  the  finger,)  we  now  order 
a  moderately  stimulating  embrocation,  consisting  of  a  beef's  gall 
mixed  in  three  half  pints  of  brandy,  rum,  or  whisky.  With  this 
the  limb  is  to  be  bathed,  (not  rubbed,)  two,  three,  or  four  times 
a  day,  as  the  patient  can  best  bear  it,  having  it  a  little  warmed 
previously.  We  would  here  suggest  a  caution  to  the  nurse,  that 
is  more  important  than  might  at  first  sight  appear — namely,  to 
literally  bathe  the  part,  and  not  to  rub  it.  Very  great  mischief 
is  oftentimes  done,  by  not  paying  attention  to  this  rule,  in  all  local 
applications;  for  nothing  but  evil  can  follow  the  other  mode,  so 
long  as  inflammation,  (however  moderate,)  continues  to  occupy 
the  parts.  But  after  this  condition  is  removed  we  believe  that 
advantage  may  be  derived  by  gentle  friction,  as  it  appears  to 
contribute  to  absorption. 


Blisters. 

These  remedies  have  been  recommended  by  almost  every 
writer  on  the  subject  of  phlegmasia  dolens — but  why,  we  are  at 
a  loss  to  understand.  For  they  are  either  not  the  appropriate 
remedies,  or  we  have  been  very  unskilful  in  their  application. 
We  have  never  had  recourse  to  blistering  but  twice,  and  8-orely 
did  we  repent  each  application.  The  disagreeable  irritation 
produced  by  its  operation  in  the  first  instance,  and  the  tedious, 
disagreeable  ulcer  that  followed,  we  imagine  might  have  been 
29 


450  PHLEGMASIA    DOLKNS. 

owing  to  some  accidental  condition  of  the  system,  or  perhaps 
idiosyncracy;  this  led  us  to  a  second  trial,  but  we  experienced 
the  same  inconveniences:  since  when,  we  have  altogether  aban- 
doned their  use.  Before  we  ordered  this  remedy,  it  is  proper 
to  state,  that  we  thought  we  had  reduced  the  system  to  the  pro- 
per blistering  point,  but  in  this  we  may  have  been  mistaken. 
Besides,  however,  the  disadvantages  just  mentioned,  arising  from 
blistering,  there  are  others  which  should  not  be  lost  sight  of  — 
namely,  preventing  other  local  applications,  and  especially  the 
one  mentioned  above,  which,  in  our  opinion,  is  very  much  more 
useful;  and,  secondly,  by  obliging  the  patient  to  maintain  one 
position  unnecessarily  long,  which  is  of  no  trifling  moment  to 
the  invalid. 


Bandaging. 

This  application  has  been  recommended  in  phlegmasia  dolens 
by  some  practitioners,  ab  initio  ;  but  our  own  experience  obliges 
us  to  say  of  it,  that  we  have  either  been  very  unfortunate  in  our 
lot  of  patients  of  this  kind,  or  if  this  be  not  so,  that  those  who 
have  professed  to  have  derived  advantage  from  it  have  mistaken 
•oedema  for  phlegmasia  dolens.  For  we  certainly  have  never  met 
with  a  case  of  this  disease,  that  could  bear,  without  severe  com- 
plainings, the  weight  of  the  bed-clothes  upon  the  affected  limb, 
much  less  a  bandage  tightly  drawn.  We,  however,  must  be  ho- 
nest, and  confess  that  we  have  ever  been  deterred  from  the  ap- 
plication of  the  bandage  in  the  early  stage  of  the  disease,  from 
the  presence  of  so  much  sensibility  in  the  part  ;  in  the  last  stage, 
we  have  known  peculiar  benefit  derived  from  its  use. 

It  is  almost  a  constant  sequence,  that  after  all  inflammation 
has  disappeared,  that  the  limb  will  remain  swollen  and  feeble. 
For  this  condition,  much  advantage  is  derived  from  bandages, 
frictions  with  the  dry  hand,  fumigating  the  limb  with  the  smoke 
of  burning  rosin,  and  exercise  in  a  carriage.  The  fumigation  is 
<5on<lucted  as  follows:  the  patient's  limb  is  to  be  placed  across  a 
tub,  in  the  bottom  of  which  there  is  a  small  chafing-dish  with 
hot  embers.  A  little  powdered  rosin  is  to  be  strewed  upon  the 
embers,  and  the  fumes  prevented  from  escaping  by  having  a  blan- 
ket spread  over  the  limb  and  tub  —  this  may  be  repeated  twice  a  day  . 

It  will  be  proper  to  observe  that  the  limb  should  be  kept  a  lit- 
tle elevated  during  the  whole  of  the  disease  ;  this  is  best  done  by 
a  board  well  protected  by  pillows,  and  placed  under  the  leg, 
with  its  lower  end  raised  as  high  as  the  patient's  feelings  will  per- 
mit. 

After  the  febrile  symptoms  have  disappeared,  the  patient's 
<iiet  may  be  a  little  more  generous:  she  may  take  thin  chocolate 


MILK    ABSCESS.  451 

a  few  oysters,  chicken  water,  or  soft  boiled  egg,  &c.,  and  if 
there  be  much  debility,  any  of  the  tonics  in  common  use  may  be 
employed  with  advantage ;  and  these  will  be  aided  by  a  well 
regulated  system  of  exercise,  which  must  of  course  be  left  to  the 
discretion  of  the  physician,  and  to  the  circumstances  of  the 
patient. 


CHAPTER  XX. 

OF    MILK    ABSCESS. 

IT  is  scarcely  necessary  to  mention  that  the  female  constitu- 
tion is  much  disposed  to  fever  after  parturition ;  the  various  cir- 
cumstances attending  gestation  and  labour,  which  are  calculated, 
on  the  one  hand,  to  produce  predisposition,  and  on  the  other  to" 
excite  fever,  leave  the  system  but  little  opportunity  to  escape  this 
evil,  unless  much  care  be  paid  to  guard  the  woman  against  all 
exciting  causes.  But,  unfortunately,  the  practice  of  those  who 
have  charge  of  females  at  this  period  is  the  very  reverse  of  what 
is  dictated  by  reason,  or  is  sanctioned  by  experience ;  and  hence 
the  production  of  fever,  in  a  greater  or  less  degree. 

From  the  changes  which  almost  invariably  take  place  during 
pregnancy,  and  immediately  after  delivery,  it  is  evident  that  it 
is  the  design  of  nature  that  the  mother  shall  provide  nourishment 
for  the  child,  at  a  certain  period  after  delivery;  and  for  the  ful- 
filment of  this  design,  milk  is  generally  formed  in  the  breasts,  as 
soon  after  delivery  as  the  necessities  of  the  child  require. 

The  evidence  of  the  capacity  of  the  mammae  for  the  production 
of  this  fluid,  consists  in  their  tumefaction ;  and  when  this  secre- 
tion is  best  formed,  it  is  neither  attended  with  excessive  swell- 
ing nor  painful  distention.  Nor  is  the  arterial  system  excited  to 
fever  for  the  purpose  of  preparing  milk,  as  is  erroneously  sup- 
posed by  many.  But  we  too  frequently  witness  the  very  reverse 
of  what  should  have  taken  place  under  proper  management, 
from  the  neglect  of  the  most  obvious  rules  of  propriety,  and 
the  total  disregard  of  the  suggestions  of  nature. 

Milk  fever  is  so  familiarly  spoken  of,  and  is  so  constantly  ex- 
pected, as  to  be  considered  a  sine  qua  non  to  the  production  of 
this  fluid :  hence  it  is  rarely  guarded  against  by  suitable  restric- 
tions ;  and  hence  the  frequency  of  the  mischief  it  creates  when 
too  violent,  or  when  unrestrained.  It  is  evident,  from  this  view 
of  the  subject,  that  there  must  be  an  error  in  the  premises  as- 
sumed respecting  this  function ;  it  is  this  error  which  wo  now 


452  MILK    ABSCESS. 

irish  very  briefly  to  point  out,  that  the  consequences  may  be 
avoided. 

It  is,  in  our  view,  an  absurdity  to  suppose  that  nature  designed 
the  child  should  be  furnished  with  nourishment  at  so  much  ex- 
pense of  health  and  comfort  to  the  mother.  That  she  should 
run  the  risk  not  only  of  ill  health  herself,  but  also  of  being  de- 
prived of  the  capacity  to  folfil  the  object  for  which  this  secretion 
is  intended ;  or,  in  other  words,  that  the  capacity  to  furnish  sup- 
*port  for  the  child  should  deprive  the  mother  of  the  power  of 
making  the  provision.  For  in  how  many  instances  do  we  see 
the  useful  purposes  of  the  Jweasts  destroyed  by  inflammation  and 
suppuration  ? 

These  considerations  make  ua  pronounce  the  fever,  which  ac- 
companies the  swelling  of  the  breasts  previously  to  the  formation 
and  discharge  of  the  milk,  a  disease -of  artificial  origin:  in  proof 
of  which,  beside  what  we  have  endeavoured  to  establish  from 
reason,  it  can  always,  or  with  rery  few  exceptions,  be  avoided, 
by  proper  observances  on  the  part  of  the  patient  herself,  and 
those  who  may  have  charge  of  her.1  The  rules  for  this  purpose 
are  simple,  and  of  easy  execution. 

First.  After  delivery  let  no  stimulating  article  be  given  the 
patient,  as  wine,  or  liquors  of  any  kind ;  spices,  chocolate,  &c. 

Second.  To  allow  her  no  animal  substance  whatever,  either  ira 
a  liquid  or  solid  form,  as  soup,  &c. 

Third.  To  permit  her  the  free  use  of  cool  drinks,  as  toast- 
water,  balm  tea,  water  alone,  or  lemonade. 

Fourth.  To  give,  on  the  morning  of  the  third  day,  a  cathartic 
of  sufficient  power  to  procure  three  or  four  evacuations. 

Fifth.  To  allow  fresh  air  to  pass  freely  through  the  room,,  and 
around  her  bed ;  and  not  to  heat  her  body  by  an  over-quantity 
of  bed-clothes,  or  by  being  surrounded  by  curtains. 

But  the  last  direction  must  be  so  conducted  as  not  to  endanger 
her  taking  cold. 

Sixth.  To  apply  the  child  early  and  frequently  to  the  breast. 

By  observing  these  rules,  we  know  that  milk  fever  may  be 
avoided  in  almost  every  instance.  But  should  these  rules  not 
be  observed,  the  distention  of  the  breasts  may  become  so  great 
as  to  excite  severe  pain ;  and  from  an  overstretching  of  the  tu- 
buli  lactiferi,  inflammation  may  be  excited,  which  may  termi- 
nate in  suppuration.2 

*  We  have  occasionally  met  with  cases  where  the  formation  of  milk  was  always 
attended  with  fever,  notwithstanding  every  precaution  was  used  to  prevent  it. 
These  instances  must  be  looked  upon  as  the  exceptions  to  the  rule ;  for  fever  to 
any  extent  does  not  occur,  perhaps,  once  in  a  thousand  times. 

*  We  shall  relate  a  very  extraordinary  case  of  the  accumulation  of  milk  in  the 
breast,  from  Prof.  Scarpa,  both  on  account  of  its  singularity  as  well  as  for  its 
practical  value. 

"  A  young  peasant  of  small  stature,  but  robust  constitution,  perceived,  ten  days 


MILK   ABSCESS.  453 

It  must,  however,  be  acknowledged  that  milk  fever  is  not  the 
only  cause  of  mammary  swelling  and  abscesses.  There  is  a 
peculiar  liability  to  this  disease  during  the  first  fifteen  or  twenty 
days  after  delivery ;  and  the  causes  may  be  various  and  obvious, 
as  well  as  special  and  hidden.  Blows  or  bruises;  bad  nipples; 
exposure  to  cold,  either  general  or  partial;  a  neglect  of  dis- 
charging the  milk  in  proper  time  from  them ;  pressure  from  stays 
or  corsets;  metastasis,  &c.  At  other  times  the  breast  swells  and 
inflames  without  our  being  able  to  determine  the  cause.  Some* 
women  are  more  liable  to  this  affection  than  others ;  and  they 
will  sometimes  have  a  repetition  of  at  with  almost  every  child 
they  may  have. 

Sometimes  a  chill  announces  a  derangement  in  the  system ; 
soon  after  which  a  pain  is  -felt  in  one  of  the  breasts,  and,  upon 
examination,  a  tumour  may  ie  generally  discovered  in  the  sub- 
stance of  it;  at  other  times  no  such  tumour  can  be  felt,  but  the 
breast  is  observed  to  swell  and  be  tender  when  pressed. 

From  this  variety  in  the  early  stage  of  this  complaint,  it  is 
evident  that  the  seat  of  inflammation  is  not  always  confined  to 
the  same  tissue  in  this  organ ;  sometimes  it  is  a  portion  of  the 
gland  which  is  attacked,  and  at  others  it  would  appear  to  be  the 
cellular  substance  alone  that  is  involved. 

When  the  gland  is  attacked,  it  suddenly  increases  in  size,  be- 
comes extremely  tender  to  the  touch,  and  gives  a  great  deal  of 
acute  pain.  The  breast  sometimes  swells  to  an  immense  size, 
especially  such  as  are  naturally  large,  and  what  is  called  fleshy. 
The  woman  finds  no  comfort  or  ease  in  any  posture,  and  the 
weight  of  the  breast  itself  occasions  much  severe  suffering. 

after  a  second  accouchement,  a  tumour  in  the  left  arm-pit,  not  preceded  by  any  in- 
flammatory symptoms  or  pain.  She  continued  to  suckle  her  infant  from  both 
breasts — but  more  especially  from  the  left,  in  the  hope  of  dissipating  the  swelling ; 
but  the  effect  was  quite  contrary  to  her  expectations,  for  the  flow  of  milk  in  that 
breast  diminished  every  day;  while  the  tumour  in  the  axilla  increased.  This  tu- 
mefaction gradually  extended  to  the  mamma,  and  at  last  occupied  the  whole  of 
it.  In  the  course  of  two  months  the  breast  got  to  such  a  size,  that  it  measured 
thirty-four  inches  in  circumference,  and  when  sitting  the  mamma  rested  on  the 
thigh  of  that  side.  The  skin  covering  this  tumour  presented  no  particular  altera- 
tion in, appearance,  except  that  it  was  rather  tense  and  shining,  the  subcutaneous 
veins  being  dilated.  Prof.  Scarpa  thrust  a  middle-sized  trocar  into  the  tumour 
near  the  axilla,  where  the  integuments  appeared  thin.  A  flow  of  pure  milk  fol- 
lowed, and  ten  pints  were  drawn  off  in  a  continued  stream.  The  celebrated  Dr. 
Frank  was  present  at  this  operation,  and  was  not  a  little  astonished.  When  the 
milk  was  evacuated,  the  mamma  was  scarcely  more  voluminous  than  the  other. 
The  wound  made  by  the  trocar  was  enlarged,  and  a  tent  introduced  for  the  pur- 
pose of  facilitating  any  farther  discharge.  The  milk  was  sent  to  M.  Scopole,  Prof, 
of  Chemistry,  and  its  analysis  showed,  that  notwithstanding  the  long  sojourn  of 
the  fluid  in  the  breast,  it  differed  in  none  of  its  physical  or  chemical  qualities  from 
the  recently  secreted  milk  of  a  female. 

'*  The  obliteration  of  the  cavity  where  the  milk  was  lodged  could  not  be  effected 
till  a  seton  was  established  there,  The  cure  was  ultimately  complete."— Med, 
Chirur.  Rev,  Jan.  1827,  p.  221. 


454  MILK   ABSCESS. 

Fever  is  excited  in  the  early  formation  of  the  local  affection, 
and  will  be  of  different  degrees  of  intensity,  as  the  inflammation 
of  the  gland  may  be  extensive,  or  as  the  system  may  be  disposed 
to  febrile  action,  or  as  it  may  be  confined  to  the  cellular  mem- 
brane. 

The  progress  of  the  inflammation  to  suppuration,  though  always 
constant  if  not  interrupted,  is  not  always  equally  rapid:  some- 
times it  requires  many  weeks  before  the  pus  will  discharge  itself, 
or  permit  an  outlet  to  be  made  for  it.  But  much  will  depend 
upon  the  seat  of  the  gland  that  may  be  affected :  if  it  be  deep, 
it  will  require  a  longer  time,  and  so  on.  It  may,  however,  be 
observed,  as  a  constant  rule,  that  the  inflamed  gland  is  always 
longer  before  it  suppurates  than  the  cellular  membrane  when  it 
is  the  seat  of  the  inflammation.  It  is  besides  very  much  more 
painful ;  and  is  attended  with  higher  sympathetic  fever,  though 
the  breast  never  becomes  so  large  as  in  the  other  instance. 

In  the  variety  of  this  complaint  now  to  be  noticed,  the  same 
remote  and  exciting  causes  may  have  operated;  though  we  can- 
not say  why  the  cellular  membrane  should  have  been  selected 
for  its  seat.  It  commences  by  the  same  general  phenomena, 
except  we  believe  that  it  is  always  preceded  by  chill ;  and  the 
first  intimation  the  woman  may  have  that  it  has  "  fallen  on  the 
breast,"  is  a  swelling  and  tenderness  of  the  part  upon  pressure. 
The  breast  is  now  rapidly  distended,  and  generally  in  an  equal 
manner;  that  is,  without  a  circumscribed  tumour  within  its  sub- 
stance. 

The  whole  progress  of  the  inflammation,  &c.,  in  this  variety, 
is  vastly  more  rapid  than  in  the  other,  and  were  we  to  judge 
merely  from  appearances,  is  more  alarming;  the  swelling  is  much 
greater,  but  the  pain  is  much  more  moderate.  Indeed,  we  have 
seen  it  run  on  to  suppuration  without  the  slightest  pain  except 
from  pressure.  This  variety  passes  through  the  same  stages  as 
the  other;  and  pretty  much  after  the  same  manner,  if  we  except 
the  rapidity  of  its  march.  We  have  seen  it  pass  on  to  suppura- 
tion in  the  course  of  a  week.  The  external  inflammation  is  much 
less  intense,  and  is  very  rarely  attended  by  oedema.  Indeed,  we 
have  seen  very  extensive  suppuration  with  scarcely  any  discolo- 
ration of  the  skin.  It  is  also  much  less  amenable  to  remedies; 
for  it  is  very  rarely  made  to  resolve  itself,  however  early  attacked 
or  vigorously  pursued  the  plan  may  be. 

The  two  varieties  may  be  combined,  and  it  is  not  very  unfre- 
quent  that  they  are:  when  this  takes  place,  the  inflammation  of 
the  gland  always  appears  first,  and  the  cellular  membrane  after- 
wards becomes  implicated,  either  from  an  extension  of  the  origi- 
nal inflammation  in  the  gland,  or  by  taking  on  this  action  later ; 
for  we  have  never  witnessed  the  cellular  membrane  injured,  un- 


MILK   ABSCESS.  455 

til  some  time  after  the  gland ;  nor  have  we  ever  seen  the  gland 
injured  from  the  inflammation  of  the  cellular  membrane. 

However,  if  the  progress  of  the  gland  to  suppuration  be  slow, 
or  the  diseased  part  be  very  deep-seated,  the  cellular  membrane 
may  remain  free  for  a  long  time,  unless  the  complaint  have  been 
treated  by  stimulating  or  other  improper  applications;  or  by  the 
early  use  of  poultices.  In  this  case,  the  part  becomes  enormously 
swelled;  the  epidermis  separates  from  the  true  skin;  a  great 
number  of  small  vesications  appear,  and  the  depending  part  of 
the  breast  becomes  oedematous,  and  sometimes  even  discharges 
a  considerable  quantity  of  serum ;  indeed,  the  whole  of  the  skin, 
covering  the  inflamed  part,  appears  thickened,  and  saturated  with 
a  fluid,  which  escapes  upon  the  smallest  injury  done  to  the  part. 

This  is  so  conspicuous  sometimes,  as  to  disguise  the  inflamed 
appearance  of  the  integuments ;  and  if  it  be  pressed  by  the  point 
of  the  finger,  the  impression  will  remain  a  long  time,  though  it 
be  not  in  a  depending  part. 


Of  the  Treatment. 

There  is  no  inflammation  of  the  phlegmonous  kind  that  runs 
on  to  suppuration  with  so  much  certainty,  and  sometimes  with 
so  much  rapidity,  as  that  which  attacks  the  mamma.  On  this 
account,  not  a  moment  is  to  be  lost  in  temporizing;  for  an  im- 
pression must  be  made,  and  that  quickly,  or  all  efforts  will  be  un- 
availing, and  the  woman  often  be  made  to  suffer  for  a  long  time 
an  acute  and  almost  never-ceasing  pain. 

Is  this  failure  to  procure  resolution  a  necessary  and  an  una- 
voidable consequence  1  Or  is  it,  in  part,  owing  to  the  first  period 
of  the  inflammation  being  either  neglected,  or  improperly  treated? 
We  have  said,  that  the  inflammation  of  the  breast  runs  on  to  sup- 
puration with  great  certainty:  by  this,  we  would  wish  to  be  un- 
derstood, that,  if  let  alone,  or  if  ill-managed,  it  will  rarely  fail  to 
suppurate ;  therefore,  if  an  attempt  be  made  to  counteract  this 
constant  tendency,  the  remedy  should  be  of  the  most  decidedly 
antiphlogistic  kind,  and  applied  early. 

But  our  want  of  success  in  resolving  mammary  inflammation, 
does  not  exclusively  arise  from  the  pertinacity  of  its  course ;  for 
there  are  several  other  causes,  which  almost  constantly  operate 
with  equal  certainty. 

First.  It  is  almost  constantly  submitted  to  the  management  of 
the  nurse,  or  subjected  to  the  "infallible  cure"  of  some  old  wo- 
man. 

Second.  To  very  inadequate  means  being  advised,  and  perse- 
vered in,  until  the  time  for  the  successful  application  of  the  pro- 
per remedies  is  irretrievably  lost ;  or, 


456  MILK  ABSCESS. 

Third.  To  stimulating  and  heating  applications  being  used, 
which  quickly  inflame  the  skin  externally ;  which  unites  with  the 
one  which  has  already  attacked  the  breast  within;  and  thus 
making  it  necessary  to  contend  with  two  enemies  instead  of  one. 

Fourth.  To  a  want  of  perseverance  and  conformity  to  the  pre- 
scriptions of  the  physician,  after  he  has  seen  the  breast,  because 
immediate  relief  may  not  be  experienced,  or  because  some  other 
plan  has  been  advised. 

Fifth.  To  a  false  delicacy  and  fear,  on  the  part  of  the  patient, 
lest  the  part  be  examined. 

The  above  causes  are  almost  sure  to  operate  against  the  early 
use  of  proper  remedies ;  and  it  is  almost  certain  to  happen,  that 
the  physician  is  not  consulted,  until  so  much  mischief  is  done,  that 
he  cannot,  but  in  part,  repair  it.  From  what  we  have  experi- 
enced, when  a  fair  chance  has  been  offered  us  to  oppose  this  dis- 
ease, we  are  of  opinion,  that  it  need  not  suppurate  near  so  often 
as  it  does.  This  holds  out  a  strong  inducement  to  the  woman 
not  to  temporize,  lest  she  incur  an  injury  that  will  not  be  re- 
paired through  life. 

It  is  never  too  soon  to  oppose  this  disease ;  and  if  a  very  early 
opportunity  occur,  the  woman  should  be  advised  as  soon  as  pos- 
sible to  employ  the  remedies,  and  to  follow  the  plan  now  to  be 
advised. 

1.  Local  Applications. 

We  have  never  found  any  application  so  successful  in  the  very 
early  stage  of  this  disease,  as  the  frequent  use  of  warm  vinegar 
to  the  part.  Its  efficacy  appears  to  us  so  certain,  when  sufficiently 
soon  employed,  that  we  need  not  in  many  instances  look  for  any 
other  remedy.  It  is  particularly  prompt  in  that  condition  of  the 
breasts,  in  which  a  want  of  proper  drawing  leaves  them ;  or  where 
they  become  greatly  and  painfully  distended  by  the  sudden 
secretion  of  milk,  but  which  cannot  be  extracted  with  ease,  or  in 
sufficient  quantity  to  relieve  the  tension,  either  from  a  defect  in 
the  external  or  inferior  extremities  of  the  tubuli  lactiferi,  or  a 
proper  conformation  of  the  nipples  themselves. 

These  accumulations  are  always  painful,  and  easily  provoked 
to  inflammation,  by  either  the  use  of  improper  food,  or  improper 
local  applications.  It  is  therefore  every  way  important  that  this 
tendency  should  be  arrested  in  limine.  For  this  purpose  the  vi- 
negar is  the  most  comforting,  and,  at  the  same  time,  the  most 
certain,  with  which  we  are  acquainted. 

This  application  is  highly  useful  also  in  the  commencement  of 
both  the  first  and  second  varieties  of  mammary  abscesses;  and 
should  be  employed  most  perseveringly  for  at  least  twenty-four 
hours.  If  the  pain  or  intumescence  be  not  abated  by  this  time, 


MILK    ABSCESS.  457 

leeches  should  be  applied  in  sufficient  number  to  abstract  from 
eight  to  ten  ounces  of  blood,  and  their  wounds  encouraged  to 
bleed  by  cloths  wrung  out  of  warm  water,  or  a  soft  bread  and 
milk  poultice.1  The  poultice  is,  however,  to  be  removed  as  soon 
as  the  bleeding  ceases,  and  its  place  to  be  supplied  by  a  piece  of 
linen  rag,  spread  with  fresh  hog's  lard;  or  a  plaster  of  hog's  lard 
and  common  flour,  incorporated  and  spread  upon  a  cloth  suffi- 
ciently large  to  cover  the  breast. 

These  applications  are  to  be  continued  until  the  leeches'  bites 
are  sufficiently  healed  to  bear  again  the  use  of  the  vinegar,  or 
the  reapplication  of  leeches.  We  would  use  the  first  when  we 
are  certain  the  disease  has  diminished ;  and  the  second,  if  we 
thought  the  disease  to  be  gaining  ground,  or  stationary.  For  it 
must  be  recollected,  no  truce  is  safe  with  this  inflammation.  We 
would  therefore  persevere  in  the  leeching  until  we  cannot  hope 
to  prevent  suppuration. 

When  this  happens,  let  it  be  remembered,  we  are  not  to  pro- 
mote the  tendency  to  suppuration  by  poulticing,  &c.;  for  this  only 
increases  the  pending  mischief,  by  the  formation  of  a  greater 
quantity  of  pus,  and  the  consequent  destruction  of  a  greater  quan- 
tity of  the  substance  of  the  breast,  by  which  its  future  usefulness 
may  be  entirely  destroyed.  It  should,  therefore,  be  a  never- 
failing  rule  to  treat  a  mammary  inflammation  as  if  it  were  not 
to  suppurate. 

From  the  period  in  which  we  look  with  certainty  for  the  breast 
to  suppurate,  to  the  time  at  which  this  takes  place,  some  satur- 
nine application  should  be  employed  steadily.  We  are  in  the 
habit  of  using  the  following  liniment  for  this  purpose,  and  we 
think  with  advantage. 

$.  01.  Olivar.  Opt.         -  -  gij. 

Liq.  Plumbi  sub.  Acetatus,  3j. 

./Ether  Vitriol.  -  5[ij. 

Tinct.  Thebaic.       -  -  3J-    M. 

A  rag  to  be  moistened  with  this  liniment,  and  applied  to  the 
part  frequently. 

Dr.  Clarke  speaks  highly  of  the  following  formula,  for  the 
same  purpose.  > 

1$.  Cerussa  acetata,  gj. 

Acetnm.  Distil,  gij.  f.  sol.  adde 

Sp.  vin.  rect.  Jj. 

Aq.  Distil.  gv.     M. 

This  is  to  be  applied  constantly  to  the  breast,  cold,  by  means 

1  Late  experience  has  convinced  us,  that  leeching  is  very  much  more  success- 
ful when  it  is  performed  below  the  breast,  instead  of  from  the  tumid  or  inflamed 
portion  of  it,  as  is  usually  done.  We  would  therefore  recommend  the  application 
of  the  leeches  to  be  made  about  an  inch  below  the  circular  margin  of  the  mammae; 


458  MILK    ABSCESS.. 

of  a  piece  of  linen.  By  this  plan  we  prevent  the  formation  of 
an  over-quantity  of  pus;  we  preserve  the  integrity  of  the  exter- 
nal covering,  and  we  prevent  oedema  almost  certainly. 

Dr.  Gaffe  states,  (Jour.  Hebdom.  vol.  ii.  p.  23,)  that  in  secre- 
tions of  milk,  attended  by  swelling  and  acute  pain,  the  follow- 
ing embrocation  acted  with  immediate  benefit  and  relief. 

]$.  Aq.  distil.  Prim.  Laur.  ceras.  %]. 
jEtherSulph.       ,   »i(     /.-^  3J- 
„',..  Ext.  G.  Opii,         ''f»  -    grs.  iij.    M. 

Apply  it  by  means  of  fine  linen,  well  wet  with  it. 

And  Ranque  recommends  another  application  in  the  following 
terms : — 

"  The  swelling  of  the  breast  which  precedes  the  formation  of 
mammary  abscesses  is  caused,  in  the  first  instance,  by  the  reten- 
tion of  milk  and  the  consequent  distention  of  the  lactiferous 
ducts.  But  this  is  not  the  only  cause  of  the  local  derangement 
that  so  rapidly  follows ;  for  the  vascular  system  of  the  mammse 
is  wonderfully  increased  preparatory  to  and  during  lactation ; 
and,  therefore,  when  this  augmented  circulation  of  the  breasts  is 
baffled  in  the  performance  of  its  proper  function, — the  secretion 
of  milk, — it  often  tends  to  form,  with  great  rapidity,  vicarious 
and  unhealthy  products.  Hence  arises  the  obstinacy  of  many 
such  cases;  and  hence  they  are  frequently  not  found  to  he  ame- 
nable to  the  common  methods  of  treating  local  congestions  and 
inflammations. 

"  All  practical  men  are  consequently  obliged  to  adopt  various 
methods  of  treatment;  and  the  skilful  accoucheur  is  often  ena- 
bled, by  attention  and  pains,  to  save  his  patient  from  the  suffer- 
ing accompanying  such  affections." 

Ranque,  impressed  with  certain  theoretical  ideas,  which  it  is 
unnecessary  here  to  discuss,  was  led  to  the  use  of  the  following 
liniment : — 

K.  Extract!  Belladonnas,  ^ij. 

Aquae  Laur.  cerasi,  £ij. 

./Etheris  Sulphurici,  ^j. 
Ft.  Linimentum. 

This  must  be  well  shaken  before  it  is  used.  It  is  to  be  rubbed 
into  the  breast  as  high  as  the  axillae,  morning  and  evening,  and 
the  brecist  must  then  be  covered  with  fine  flannel  soaked  in  the 
liniment.  This  proceeding  must  be  repeated  every  day,  until 
the  swelling  disappears,  which  is  usually  on  the  second  or  third 
day.  The  ether  has  a  smell  which  to  some  is  very  disagreeable ; 
but  they  ought  to  bear  this  inconvenience,  if  possible,  for  it  adds 
essentially  to  the  efficacy  of  the  remedy. 


* 

MILK   ABSCESS.  459 


2.  Regimen. 

In  aid  of  the  local  applications  mentioned  above,  the  patient 
must  be  restricted  to  a  severe  antiphlogistic  regimen ;  no  ani- 
mal substance  in  any  form  should  be  allowed ;  nor  any  kind  of 
liquor  be  permitted.  She  may  have  tea;  weak  coffee;  milk  and 
water ;  rennet-whey ;  very  thin  tapioca ;  thin  sago ;  arrow-root ; 
roasted  apples ;  fruits  of  the  season,  &c.  Her  drink  should  be 
water;  toast- water;  molasses  and  water;  apple-water;  or  thin 
lemonade. 


3.  Purging,  £c. 

Her  bowels  should  be  freely  purged  daily,  by  any  of  the  neu- 
tral salts,  magnesia,  senna,  &c.  And,  should  there  be  much 
fever,  she  should  lose  blood  from  the  arm,  again  and  again,  if 
necessary. 

She  should  be  confined  to  the  bed,  and  made  to  lie  upon  her 
back,  to  favour  the  retiring  of  the  blood  from  the  breast.  The 
breast  should  be  very  lightly  covered,  instead  of  being  enveloped 
in  many  folds  of  flannel.  The  temperature  of  the  air  should  be 
very  moderate,  and  her  drinks  cool. 

This  regimen,  &c.,  should  be  persevered  in,  though  suppura- 
tion be  inevitable ;  indeed,  it  should  be  continued  until  the  matter 
13  discharged,  either  spontaneously,  or  by  art. 


4.  Puncturing. 

If  matter  form  in  spite  of  our  exertions,  the  breast  must  be 
treated  as  an  abscess  usually  is.  Our  general  rule  is,  to  let  it  dis- 
charge itself,  if  the  collection  be  small ;  but  if  the  quantity  be 
large,  and  the  skin  very  thin  and  dark-coloured,  we  always  punc- 
ture it  with  a  lancet,  and  take  from  it  but  a  small  quantity  of  pus 
at  a  time.  After  we  have  allowed  an  ounce,  or  a  little  more,  to 
flow,  we  place  a  piece  of  lint  upon  the  orifice,  and,  for  this  time, 
stop  any  farther  discharge.  At  the  end  of  three  or  four  hours  we 
direct  the  dressings  to  be  removed,  and  a  fresh  quantity  allowed 
to  escape,  and  so  on,  until  the  whole  has  passed. 

If  there  be  pain  at  this  time,  we  direct  a  soft  bread  and  milk 
poultice;  if  there  be  none,  we  have  it  dressed  with  simple  cerate. 
Sometimes  the  discharge  from  the  wound  is  arrested  by  a  portion 
of  dead  cellular  membrane  getting  into  the  orifice;  and  this  is 
particularly  the  case  in  the  second  variety  of  this  abscess.  If 
this  happen,  it  should  be  removed  by  taking  hold  of  it  with  a 


'      . 

460  MILK   ABSCESS. 

piece  of  rag  interposed  between  the  thumb  and  finger.  Should 
this,  however,  occasion  pain,  or  blood  discharge  itself  while 
making  this  effort,  it  must  be  desisted  from  ;  the  external  portion 
cut  off  close  to  the  breast,  by  a  pair  of  sharp  scissors,  and  the 
portion  in  the  orifice  pushed  back  by  the  extremity  of  a  probe, 
and  kept  by  this  means  from  obstructing  the  wound,  until  a  suffi- 
cient quantity  of  the  pus  be  extracted.  This  has  to  be  frequently 
repeated  in  some  cases. 

Some  are  in  the  practice  of  making  a  large  orifice  for  the  dis- 
charge of  the  matter;  but  this  is  a  reprehensible  practice.  It  is 
sure  to  destroy  a  large  portion  of  the  surrounding  skin,  which  is 
now  weakened  by  distention  ;  it  will  also  occasion  a  large  and 
deep  wound,  in  which  granulations  spring  up  too  rapidly  for  the 
part  to  heal  soundly.  Fungus  is  almost  sure  to  arise  ;  and  a  long, 
painful  and  weakening  sore  is  left;  all  of  which  might  have  been 
avoided  by  pursuing  the  plan  just  recommended. 


5.   Caustic. 

It  is  not  unfrequent  for  milk  or  serum  to  pass  through  the 
wound  when  it  is  near  healing  ;  and  this  continues  sometimes  to 
be  maintained  a  long  time  :  this  is  owing  to  a  small  portion  of 
fungus  having  possession  of  the  orifice  —  this  should  be  removed 
by  the  application  of  the  nitrate  of  silver;  which  will  permit  the 
wound  to  heal  immediately,  unless  it  be  the  opening  of  a  sinus  of 
some  depth.  If  the  sinus  be  superficial,  it  is  to  be  removed,  by 
enlarging  the  orifice  by  caustic,  and  then  apply  pressure  ;  or  by 
exciting  inflammation,  by  injecting  in  it  a  solution  of  corrosive 
sublimate,  in  the  proportion  of  a  grain  to  an  ounce  of  water. 


6.  Seton. 

But  when  a  deep-seated  portion  of  the  gland  has  suppurated, 
the  wound  sometimes  will  not  heal  ;  a  deep  sinus  is  formed,  which 
continues  to  yield  pus,  in  spite  of  every  attempt  to  close  the  ori- 
fice. For  the  destruction  of  this  sinus,  Mr.  Hey  recommends 
cutting  through  the  substance  of  the  breast,  to  its  bottom  ;  an 
operation,  confessedly  of  great  severity,  and  one  which  very 
few  would  have  courage  to  encounter.  Yet,  as  it  is  a  disease 
which  never  cures  itself;  as  it  is  always  attended  by  more  or  less 
induration  of  the  breast  ;  and  as  it  always  excites  much  uneasi- 
ness, and  not  unfrequently  great  alarm,  lest  it  be  the  forerunner 
of  cancer,  the  woman  becomes  very  desirous  that  something  should 
be  done  for  her  relief,  and  will  therefore  willingly  submit  to  any 
moderate  degree  of  pain,  or  privation,  for  this  purpose. 

Fortunately,  a  much  milder  operation  than  Mr.  Hey's  has  been 


MILK   ABSCEBS.  461 

recommended ;  and  it  has  succeeded  most  satisfactorily  in  all  the 
cases  in  which  it  has  yet  been  tried.  This  improvement  is  the 
seton  operation  of  Dr.  Physick,  to  whom  the  profession  is  already 
so  largely  indebted  for  his  very  many  valuable  suggestions  in 
practical  surgery. 

This  operation  is  performed  in  the  following  manner:  a  probe 
is  passed  along  the  sinus,  so  far  as  it  will  go.  If  the  direction  be 
outward,  towards  the  portion  of  the  breast  next  to  the  arm,  so 
much  the  better ;  but  if  not,  let  the  point  be  carried  towards  the 
side  it  most  inclines  to.  When  the  probe  has  passed  as  far  as  it 
can  along  the  sinus,  the  point  is  urged  laterally,  until  its  point  is 
perceived  to  press  against  the  skin  without ;  at  this  point  it  is  to 
be  cut  down,  and  the  probe  forced  so  far  through  this  little  wound, 
as  to  enable  the  operator  to  seize  it  either  with  his  thumb  and 
finger,  or  with  a  pair  of  forceps.  The  probe,  which  was  pre- 
viously armed  with  a  portion  of  braid,  soft  half-inch  tape,  or  a 
piece  of  silk  riband,  is  now  to  be  drawn  through. 

The  seton  is  permitted  to  remain  from  three  to  four  weeks, 
without  being  disturbed ;  or  until,  from  the  healthy  appearance 
and  diminished  quantity  of  pus,  there  is  reason  to  believe  the 
sinus  will  heal  by  withdrawing  it.  But,  should  there  be  a  ten- 
dency in  the  external  orifices  to  close  too  soon  after  the  seton  is 
removed,  or  before  the  sinus  is  supposed  to  be  healed,  they  are 
kept  open  by  a  small  piece  of  bougie,  or  sponge  tent,  until  the 
healing  takes  place. 

Should  the  matter  become  hard  around  the  seton,  and  obstruct 
the  farther  flow  of  pus,  it  must  be  removed  by  carefully  washing 
it  with  warm  water,  or  by  the  application  of  a  soft  bread  and 
milk  poultice.  Dr.  Physick  assured  us,  that  this  plan  had  suc- 
ceeded entirely  to  his  satisfaction,  in  the  several  trials  he  had 
given  it;  one  of  which  we  witnessed  ourselves.  And  he  is  of 
opinion,  that  this  operation  will  always  succeed  if  there  be  no 
cancerous  tendency  in  the  parts. 


7.  After- Treatment. 

After  the  healing  of  the  abscess,  a  considerable  hardness  re- 
mains in  the  breast,  which  will  require  a  long  time  for  its  ab- 
sorption; this  creates  a  good  deal  of  uneasiness  in  the  patient, 
lest  it  be  a  scirrhus.  On  this  point,  her  fears  may  be  composed ; 
as  the  tumour  which  remains  will  eventually  be  taken  up  by  the 
absorbents,  as  it  is  nothing  but  coagulated  lymph ;  but  the  ab- 
sorption may  be  promoted  by  keeping  the  part  warmly  covered, 
or  by  the  repeated  application  of  warm  vinegar.  If  this  occur 
in  winter,  a  piece  of  rabbit  skin  may  be  used,  with  the  furred 


462  HYSTERIA. 

side  next  to  the  breast;  if  in  summer,  a  piece  of  fine  flannel  will 
answer  very  well.  Or  the  part  may  be  rubbed  twice  a  day  with 
opodeldoc. 


CHAPTER  XXI. 


HYSTERIA. 

THE  nervous  system,  like  the  vascular,  the  muscular,  &c.,  is 
liable  to  certain  and  specific  derangements.  The  symptoms 
arising  from  this  disordered  condition  of  the  brain  and  nerves 
are  familiarly  called  nervous;  but  to  which  it  would  be  difficult 
to  affix  any  precise  or  distinct  meaning,  as  they  are  not  only 
very  numerous,  and  varied,  but  at  the  same  time  peculiar,  and 
not  always  well  defined.  This  variety  creates  a  difficulty,  which, 
we  are"  persuaded,  every  practitioner  has  encountered  in  the 
commencement  of  his  practical  career;  but  with  which  he  be- 
comes familiar  from  a  longer  acquaintance  and  study  of  mor- 
bid phenomena;  and  is  at  length  able  to  decide,  with  tolerable 
certainty,  the  extent  of  their  agency  in  modifying  the  diseases 
of  the  other  systems;  or  can  determine,  very  nearly,  in  what 
degree  they  may  be  considered  as  belonging  to  the  nervous  sys- 
tem. 

The  disease  under  consideration  may  be  justly  looked  upon  a< 
the  assemblage  of  very  many  symptoms,  the  nature  and  extent 
of  which  must  necessarily  be  much  diversified,  as  the  seats  of 
sympathy  in  several  organs  of  the  body  may  be  in  a  fewer  or  a 
greater  number;  and  as  these  may  be  more  or  less  important. 

The  ancients  were  of  opinion  that  the  affections  under  consi- 
deration arose  from  some  derangement  or  lesion  of  the  uterus ; 
on  which  they  bestowed  very  many  gratuitous  powers.  Indeed, 
many  moderate  practitioners  are  still  of  the  opinion  so  boldly 
advanced  by  their  predecessors.  Dr.  Good1  says,  "  With  a  mor- 
bid condition  of  this  organ,  indeed,  hysteria  is,  in  many  instances, 
very  closely  connected,  though  it  is  going  too  far  to  say,  that  it 
is  always  dependent  upon  such  condition;  for  we  meet  occasion- 
ally with  instances,  in  which  no  possible  connexion  can  be  traced 
between  the  disease  and  the  organ,  and  sometimes  witness  it  in 
males  as  decidedly  as  in  females." 

That  a  certain  condition  of  the  nerves  of  the  uterus,  like  any 

'  Study  of  Medicine,  vol.  iii.  p.  352.     Am.  Ed. 


HYSTERIA.  463 

other  portion  of  the  body,  may  give  rise  to  that  combination  of 
symptoms  termed  hysteria,  or  from  some  lesion  of  other  portions 
of  this  organ  the  nerves  of  the  part  so  injured  may  be  seconda- 
rily affected,  there  cannot  be  a  doubt.  But  that  every  derange- 
ment of  function,  or  even  lesion  of  this  organ,  will  produce  hys- 
teria, there  is  the  most  unquestionable  reasons  to  deny ;  indeed, 
it  seems  that  when  the  uterus  is  seriously  affected,  as  in  cancer, 
there  is  very  often  an  absence  of  those  distressing  symptoms 
which  every  body  agrees  to  call  nervous.1 

Many  facts  seem  to  confirm  this  last  observation.  For  when 
this  organ  is  labouring  under  an  active  malady,  as  inflammation, 
&c.,  there  is,  for  the  most  part,  nay,  almost  always,  an  exemp- 
tion from  the  symptoms  constituting  hysteria ;  for  there  must  be 
a  particular  condition  of  the  nerves  of  the  part  to  give  rise  to 
the  symptoms  called  nervous  or  hysterical ;  or,  in  other  words, 
there  must  exist  some  peculiar  condition  of  the  nerves  of  an 
organ,  before  the  brain  or  other  portions  of  the  nervous  system 
are  called  into  sympathy  with  it. 

The  seat  of  hysteria  would  seem  to  be  in  the  brain  itself,  in- 
stead of  the  uterus ;  but  the  exact  condition  of  this  organ  that 
gives  rise  to  the  various  phenomena  of  this  affection,  is  by  no 
means  ascertained.  We  know  so  little  of  the  state  of  this  organ 
when  in  health,  that  we  may  very  readily  be  deceived  by  the 
appearances  furnished  by  post-mortem  examinations.  It  is  but 
reasonable  to  suppose  that  each  individual  has  some  difference, 
or  peculiarity  of  organization  of  the  brain;  since,  in  no  two, 
perhaps,  are  its  functions  performed  precisely  alike,  at  least  as 
far  as  can  be  determined  by  external  phenomena.  Nor  is  it  pro- 
bable that  we  shall  ever  be  much  more  enlightened  upon  this 
subject;  since  we  know  nothing,  or  but  very  little,  of  its  condition 
inr  absolute  health. 

Our  knowledge  of  the  human  brain  is  exclusively  derived  from 
dissections  performed  after  death ;  but  what  alterations  may  not 
take  place  during  the  progress  of  disease,  or  in  articulo  mortis? 
It  is  true  we  are  very  often  told  by  those  who  have  inspected  this 
mass  after  death,  "that  the  brain  was  found  perfectly  healthy." 

But  where  can  a  standard  of  comparison  be  found  to  warrant 

1  The  reviewer  of  this  work,  in  the  North  American  Med.  and  Surg.  Journal, 
vol.  iii.  p.  318,  says  that "  no  one,  at  least  of  any  authority  in  pathology,  has  ever 
maintained  that  the  irritation  producing  hysteria  was  located  in  the  uterus,  to  the 
exclusion  of  cephalic  irritation.  The  gentleman  appears  to  have  forgotten,  or 
overlooked,  the  opinion  of  Villermay  upon  this  subject.  This  author  is  a  stre- 
nuous advocate  for  uterine  influence  in  this  complaint;  and  that  as  far  as  we  un- 
derstand a  great  many  of  his  (to  say  the  least  of  them,)  singular  and  very  doubt- 
ful notions,  altogether  independent  of  that  condition  of  the  brain  which  we  think 
essential  to  its  existence.  He  considers  hysteria  a  misnomer,  if  this  disease  be 
not  exclusively  confined  to  females;  and  which  he,  at  great  length,  attempts  to 
prove  is  the  case,  because  this  organ  is  so  universally  the  seat  of  this  complaint. 


464  HYSTERIA. 

such  a  conclusion  ?  Because  there  was  no  evident  lesion  of  this 
organ,  does  it  follow  that  it  was  in  a  perfectly  healthy  condition 
during  life?  Is  there  not  much  reason  to  doubt  this,  as  we  very 
rarely  see  instances  of  death  where  this  organ  performs  its  func- 
tions without  more  or  less  aberration,  especially  towards  the  last 
moments  of  life?  And  we  know  of  very  many  others  where  the 
seat  of  disease  had  been  certainly  in  the  brain,  as  far,  at  least, 
as  can  be  determined  by  symptoms,  yet  after  death  it  has  been 
declared  to  have  been  found  in  a  state  of  health. 

We  are  frequently  told  of  altered  structure,  of  inflammation, 
of  too  great  a  density,  too  great  a  degree  of  softness,  &c.  of  this 
organ.  Now  these  facts  only  go  to  prove  that  in  certain  con- 
ditions of  this  organ  certain  changes  must  have  taken  place. 
But  does  it  follow,  that  in  the  instances  in  which  no  evident 
change  has  been  found,  that  this  organ  was  in  a  state  of  abso- 
lute health,  either  as  regards  action  or  organization?  All  de- 
rangements of  this  organ  cannot  consist  in  the  alterations  above 
mentioned.  There  must  be  many  others,  where  the  attempt  to 
develope  them  by  the  knife  would  be  vain. 

It  is,  therefore,  not  sufficient  for  the  best  purposes  of  patho- 
logy, to  declare,  that  the  brain  was  not  concerned  in  the  disease 
of  which  the  patient  may  have  died,  because  no  trace  of  derange- 
ment presented  itself  upon  a  post-mortem  examination.  Who 
will  pretend  to  point  out,  by  the  knife,  the  difference  of  condition 
of  the  brains  of  the  moping  hypochondriac  and  the  furious  mad- 
man? between  the  pitiable  idiot  and  the  man  of  genius,  &c.  &c.? 
Has  the  cause  of  idiopathic  epilepsy,  of  tetanus,  of  hydrophobia, 
ever  been  unequivocally  detected  by  any  marks  left  in  the  brain 
after  death? 

It  is  true,  we  have  been  furnished  with  the  observations  of  the 
pathologist  and  anatomist  upon  each  of  these  points ;  but  the  ap- 
pearances described  by  them  have  so  often  been  seen  where 
neither  of  these  diseases  was  the  cause  of  death,  as  to  render  it 
extremely  doubtful  of  their  agency  in  the  production  of  them. 
Besides,  we  have  much  reason  to  believe  that  a  deranged  action 
of  the  brain  may  cause  death,  without  leaving  the  slightest  evi- 
dence of  its  nature. 

No  direct  proof,  perhaps,  can  be  offered  that  the  brain  is  the 
seat  of  hysteria;  for  few  dissections  can  have  been  made  with  a 
view  to  ascertain  its  condition  in  this  disease,  as  it  very  rarely 
proves  mortal;  and  of  these  few,  none  occur  to  my  recollection.1 

1  I  cannot  call  to  mind  the  dissection  of  a  "nervous  person,"  (if  I  have  ever 
met  with  one,)  in  which  any  particular  condition  of  the  brain  is  noticed,  though 
many  examinations  have  been  made  of  those  who  have  died  of  "  nervous  disor- 
ders." Upon  this  subject  Whytt  observes,  "Although  it  appears,  from  the  dissec- 
tion of  those  who  have  died  of  them,  that  the  stomach  and  intestines,  liver,  spleen, 
amentum,  mesentery,  or  uterus,  have  frequently  been  found  obstructed,  scirrhous, 
or  otherwise  unsound;  yet,  as  in  many  other  cases  of  the  same  disorders,  no  such 


HYSTERIA.  465 

The  opinion  is  founded  rather  on  the  causes  of  this  disease,  both 
remote  and  exciting ;  upon  the  phenomena  which  it  presents ;  and  <• 
the  remedies  most  successful  in  relieving  the  paroxysms,  and  in- 
terrupting their  returns ;  of  these  I  shall  speak  in  their  proper 
places. 

The  brain,  like  almost  every  other  portion  of  the  body,  has 
parts  which  more  readily  sympathize  with  it  than  others;  and 
these  sympathies  show  themselves  variously,  not  only  as  regards 
phenomena,  but  very  differently  in  different  portions  of  the  sys- 
tem, as  the  brain  may  be  labouring  under  one  affection  or  other. 
Thus,  in  passions  or  emotions  of  the  mind,  the  liver  and  stomach 
are  wont  to  be  disturbed;  the  one,  to  the  more  abundant  secre- 
tion of  bile,  and  the  other  to  the  effort  of  throwing  it  off.  In 
melancholy,  the  bowels  become  torpid:  the  stomach  dyspeptic, 
&c.  In  tetanus  the  whole  muscular  system  is  involved,  or  only 
certain  portions  of  it.  In  hydrophobia  the  muscles  of  deglutition 
and  respiration,  and  sometimes  the  whole  muscular  system,  &c. 

&C.1 

In  hysteria  this  peculiar  condition  of  the  brain  certainly  exists ; 
but  in  what  this  peculiarity  consists,  we  can  neither  name  nor 
demonstrate ;  yet,  in  this  state  we  see  many  powerful,  nay,  awful 
sympathies  called  forth,  and  give  rise  to  a  suit  of  symptoms, 
which  are,  by  common  consent,  called  nervous.  There  is  no 
part  of  the  human  body  that  may  not  have  its  nerves  to  sympa- 
thize with  this  condition  of  the  brain ;  and  thus  give  rise  to  several 
phenomena  peculiar  to  the  part  thus  sympathizing;  hence,  the 
"Protean  shapes'1  this  disease  is  said  to  assume.  Thus,  if  the 
nerves  of  the  stomach  be  the  principal  seat  of  sympathy,  we  shall 
have  a  train  of  gastric  symptoms  presenting  themselves;  such  as 
eructations ;  sour  belchings ;  gastrodynia ;  pyrosis ;  indigestion ; 
globus  hystericus,  &c.  If  the  intestines,  we  may  find  tympanitis ; 
spasms;  diarrhoea;  costiveness;  contractions  of  the  abdominal 
muscles,  &c.  If  the  liver,  an  inordinate,  or  diminished  secretion 
of  bile;  biliary  calculi;  pain  in  the  right  side;  with  a  sense  of 
fulness  and  distention ;  obstructions,  &c.  If  the  kidneys,  an  im- 
moderate flow  of  pale  or  limpid  urine;  or  a  very  much  dimi- 

morbid  appearances  have  been  observed  in  the  body  after  death ;  it  follows  that 
these  symptoms  may  frequently  proceed  from  causes,  which,  eluding  our  senses, 
are  not  to  be  discovered  by  dissection.  Nay,  obstructions,  scirrhi,and  other  dis- 
orders of  the  viscera,  observed  in  those  who  have  died,  after  suffering  from  long 
nervous  ailments,  seem  sometimes  to  have  been  the  consequences  of  a  long  state 
of  bad  health,  rather  than  the  causes  of  it.''  Works,  p.  584. 

1  What  renders  it  more  probable  that  the  brain,  or,  at  least,  the  origin  of  the 
nerves  of  this  organ,  is  the  seat  of  that  condition  which  gives  rise  to  the  convul- 
sive motions  in  hysteria,  are  the  experiments  and  observations  of  Dr.  Philip,  in 
his  inquiry  on  "  the  relation  between  the  nervous  and  sanguiferous  systems."  He 
says,  that"  neither  mechanical  nor  chemical  stimuli,  applied  to  the  nervous  system, 
excite  the  muscles  of  voluntary  motion  unless  they  are  applied  near  the  origin 
of  the  nerves,  and  spinal  marrow."  Phil.  Trans,  for  1815,  p.  444. 

30 


466  HYSTERIA. 

nishcd  secretion ;  and  the  little  yielded  of  a  very  high  colour, 
and  sometimes  very  offensive ;  severe  pain  in  the  parts,  resem- 
bling the  passage  of  a  calculus ;  bloody  urine,  &c.  If  the  bladder, 
incontinence  of  urine ;  mucous  discharges ;  retention,  &c.  If  the 
heart,  we  shall  have  palpitations,  irregular  contractions,  faint- 
ness,  &c.  If  the  scalp,  a  coldness  on  the  top  of  the  head ;  or  a 
sense  of  heat  on  the  back  part ;  great  tenderness  to  the  touch ; 
clavus  hystefricus.  If  the  muscular  system,  violent  convulsions, 
or  nervous  twitchings  as  they  are  called,  &c. 

In  hysteria  certain  parts  of  the  body  sympathize  with  the  brain 
more  constantly  and  extensively  than  others;  indeed,  it  seems, 
that  when  the  brain  is  in  that  particular  condition  which  gives 
rise  to  the  phenomena  constituting  this  disease,  that  the  kidneys, 
the  stomach,  the  oesophagus,  the  heart,  and  the  scalp,  almost  al- 
ways participate  in  the  affection,  and  declare  its  existence.  It 
is  not  necessary  to  the  detection  of  hysteria,  that  all  these  parts 
should  be  simultaneously  affected ;  they  may  be  so  in  a  stronger 
or  weaker  force  of  combination ;  or  they  may  present  themselves 
separately  and  alternately;  but  whenever  all,  or  even  one  of 
them  exists,  this  peculiar  condition  of  the  system  betrays  itself, 
and  marks  out  the  plan  to  be  pursued  for  its  relief. 

It  may  be  justly  doubted  whether  any  of  these  symptoms  show 
themselves  during  the  time  the  system  is  labouring  under  high 
arterial  action  ;  as  in  fevers  of  great  force,  or  those  of  malignant 
tendency;  though  they  are  by  no  means  incompatible  with  a 
plethoric  condition  of  the  system;  or  with  fevers  of  very  mode- 
rate force ;  a  circumstance  to  be  noticed,  as  it  is  of  much  prac- 
tical importance. 

Hysteria  does  not  really  create  or  produce  the  variety  of  dis- 
eases insisted  on  by  Sydenham ;  the  nerves  of  the  different  por- 
tions of  the  body,  when  under  the  hysterical  impression,  similate 
a  disease  to  which  the  part  is  liable.  Thus,  a  fit  of  the  stone 
has  been  similated,  but  a  stone  has  not  been  generated ;  diabetes 
has  been  imitated,  but  a  genuine  diabetes  has  not  been  pro- 
duced ;  various  affections  arising  from  ossifications  of  the  heart 
and  large  arteries,  have  been  mimicked,  but  the  assumption  has 
been  evanescent,  &c.  &c. 

Therefore,  as  remarked  above,  when  the  nerves  of  certain 
parts  of  the  body  become  affected  by  sympathizing  with  the  brain 
when  disposed  to  hysteria,  the  part  thus  situated  will  assume 
that  peculiarity  of  action,  which  it  seems  agreed  upon  to  call 
nervous,  or  hysterical,  if  you  please. 

Syncope,  or  a  disposition  to  it,  may  be  considered  as  a  symp- 
tom of  the  hysterical  affection,  and  may  be  looked  upon,  if  not 
as  one  of  the  most  dangerous  forms,  at  least  as  one  of  the  most 
frightful.  Syncope  may  be  regarded  as  A  universal,  but  tempo- 
rary paralysis  of  all  the  muscular  portions  of  the  body :  this  con- 
dition of  the  system  doubtless  arises  from  some  peculiar  state  of 


HYSTERIA.  467 

the  brain ;  and  it  would  most  probably  be  in  vain,  even  where 
syncope  had  been  a  habit  of  the  system,  (if  we  may  so  term  it,) 
to  recognise  the  peculiarity  of  the  brain,  which  gave  rise  to  them, 
by  a  post  mortem  search. 

In  epilepsy  the  whole  of  the  muscular  system  is  for  awhile  vio- 
lently agitated,  while  the  lymphatic  and  glandular  systems  seem 
to  be  but  little  disturbed :  yet  in  hysteria,  all  these  systems  are 
made  to  participate  with  this  condition  of  the  brain  in  certain 
cases,  while  in  others  the  glandular  alone  may  be  involved.  The 
phenomena  presented  in  hysteria  will  therefore  vary,  as  it  may 
be  the  nerves  of  one  or  of  another  part  of  the  body  that  may  be 
affected,  as  the  force  of  the  exciting  cause  may  be  more  or  less 
powerful,  or  as  the  predisposition  may  be  greater  or  less. 

Hysteria  has  been  called  a  Proteus  by  Sydenham ;  and  he  de- 
clares, this  disease  *'is  not  more  remarkable  for  its  frequency, 
than  for  the  numerous  forms  under  which  it  appears,  resembling 
most  of  the  distempers  wherewith  mankind  are  affected.  For  in 
whatever  part  of  the  body  it  be  seated,  it  immediately  produces 
such  symptoms  as  are  peculiar  thereto ;  so  that  if  the  physician 
be  not  a  person  of  judgment  and  penetration,  he  will  be  mistaken, 
and  suppose  such  symptoms  to  arise  from  some  essential  disease 
of  this  or  that  particular  part,  and  not  from  the  hysteric  passion." 
Ept.  to  Dr.  Cole,  vol.  ii.  p.  106. 

The  account  of  hysteria  as  given  by  Sydenham  has  been  ac- 
ceded to  by  almost  every  medical  writer  since  his  time,  and  its 
history  creates  a  belief  that  this  affection  can  really  produce 
almost  every  disease  to  which  the  body  is  liable :  hence,  the  va- 
rious forms  or  disguises  under  which  it  is  described. 

Thus  Sydenham  declares  the  hysteric  passion  appears  under 
the  form  of  apoplexy,  of  epilepsy,  violent  pain  in  the  head,  with 
excessive  vomiting,  palpitation  of  the  heart,  a  dry  cough,  iliac 
passion,  pains  resembling  a  fit  of  the  stone,  cholera  morbus,  swell- 
ing of  the  hands,  fauces,  shoulders,  thighs  and  legs,  pains  in 
sound  teeth,  pains  in  the  back,  remarkable  coldness  of  the  sur- 
face of  the  body,  copious  discharges  of  limpid  urine,  sometimes 
fetid  urine  with  acid  eructations,  disturbance  of  mind,  and  low- 
ness  of  spirits,  &c.  &c. 

All  these  symptoms,  or  certainly  a  great  part  of  them,  may  by 
turns  affect  the  same  individuals  at  different  periods,  as  predispo- 
sitions exist,  or  as  exciting  causes  may  be  applied ;  and  this  with- 
out any  manifest  disease  in  either  the  vascular,  muscular,  or 
lymphatic  systems;  or  several  of  them  may  be  present,  when 
some  one  of  these  systems  may  be  labouring  under  a  disease  of 
mild  form.  These  combinations,  however,  as  just  observed,  are 
rarely  present  when  the  arterial  system  is  powerfully  excited,  as 
in  fever;  nor  when  the  muscular  system  is  much  involved,  as  in 
general  rheumatism,  or  in  tetanus.  They  frequently  combine 


468  HYSTERIA* 

with  affections  of  the  lymphatic  system ;  because  in  affections  of 
this  system,  when  moderate,  neither  the  vascular  nor  muscular 
systems  are  much  implicated;  but  when  the  glandular  or  lym- 
phatic system  becomes  much  diseased,  as  in  the  last  stages  of 
scrofula,  the  nervous  or  hysterical  symptoms  will  disappear, 
should  they  have  been  present. 


SECT.  I. — Of  the  Predisposing  Causes  of  Hysteria. 

It  seems  that  whatever  has  a  tendency  to  destroy  the  general 
tone  of  the  system,  especially  if  this  be  done  gradually,  will  dis- 
pose the  body  to  hysteria ;  hence,  the  certain  influence  of  too  se- 
dentary a  life,  over  stimulating  diet  or  medicines,  if  too  long  con- 
tinued, long  watching,  disappointed  hope,  or  abused  affection, 
grief,  terror,  prolonged  anxiety,  &c.  Some  of  these  causes  will 
act,  by  preventing  the  nervous  system  acquiring  its  proper  tone, 
others  by  taxing  its  sensibility  too  highly,  and  others  by  exhaust- 
ing or  too  much  diminishing  its  energies,  &c.  Hence,  hysteria 
is  most  frequent  in  females,  and  at  that  period  which  intervenes 
between  puberty  and  the  final  cessation  of  the  menses. 

About  the  period  of  puberty,  and  for  a  considerable  time  after, 
the  system  is  much  more  affected  by  the  remote  causes  of  hys- 
teria. Before  puberty,  the  system  seems  less  liable  to  affections 
the  remote  causes  of  which  act  upon  the  brain  and  nerves,  than 
after  this  state  has  arrived ;  for  before  this  period,  improper  phy- 
sical education,  or  other  causes,  have  not  generally  had  time  to 
do  their  worst,  by  impairing,  or  interrupting  the  force  of  the 
muscular  system;  or  by  exalting  the  sensibility  of  the  nervous. 
And  after  the  menses  have  ceased,  the  nervous  system  has  less 
sensibility,  provided  it  had  not,  up  to  that  period,  been  habitually 
too  much  excited. 

There  are,  however,  exceptions  to  this  rule:  I  have  seen  seve- 
ral instances  of  well-developed  hysteria,  before  the  menses  had 
made  their  appearance;  and  a  number  after  this  discharge  had 
ceased.  From  all  I  have  observed,  there  is  no  absolute  con- 
nexion or  sympathy  between  any  particular  condition  of  the  ute- 
rus, and  hysteria;  that  is,  as  genuine  cause  and  effect.  It  is 
true  I  have  repeatedly  seen  hysteria  in  its  most  aggravated  form, 
attend  each  return  of  the  menses  in  very  young  women ;  but  in 
all  such  cases  the  particular  state  of  the  uterus,  at  these  periods, 
served  but  as  an  exciting  cause  to  this  affection ;  for  hysteria 
could  be  excited  in  these  individuals  at  other  times  than  the  men- 
struous  periods,  by  causes  usually  capable  of  producing  it.  Be- 
sides, I  have  seen  a  number  of  instances  of  genuine  hysterical 
paroxysms  in  men;  especially  in  those  who  have  possessed  great 
social  virtues,  and  readily  moved  to  strong  sympathies.  I  do 


HYSTERIA.  469 

not  reckon  as  instances  the  idiotic  blubbering  or  the  unmeaning 
laughter  of  very  old  men. 

Whytt1  considers  as  "occasional  causes  of  hysteria,"  &c.2 

1st.  Some  morbid  matter  bred  in  the  blood. 

2d.  The  diminution  or  retention  of  some  accustomed  evacua- 
tion, as  the  menses,  or  hemorrhoids. 

3d.  The  want  of  a  sufficient  quantity  of  blood,  or  of  blood  of 
a  sufficient  density. 

As  regards  the  first,  there  is  much  reason  to  doubt  whether 
any  absolute  cause  of  disease  ever  formally  exists  in  the  blood,3 
at  least  we  have  no  decided  evidence  of  such  a  condition ;  the 
instances  produced,  purporting  to  illustrate  or  prove  this  as- 
sumption, can  be  better  explained  by  known  laws  of  the  animal 
system,  which  do  not  recognise  this  condition  of  the  circulating 
mass. 

The  matter  of  gout,  as  it  is  called,  is  very  frequently  blamed 
for  the  production  of  nervous  complaints ;  but  whether  any  such 
substance  really  exist,  is  much  to  be  doubted:  at  all  events  the 
proofs  offered  of  it  are  very  equivocal  and  not  to  be  relied  on. 

As  to  the  second  set  of  causes,  namely,  "the  diminution  or 
retention  of  some  accustomed  evacuation,"  they  can  only  be  con- 
sidered as  producing  some  general  affection  of  the  system  with 
which  the  nervous  system  may  sympathize ;  and  if  the  predispo- 
sition is  to  hysteria,  hysteria  will  show  itself;  if  to  epilepsy,  epi- 
lepsy will  follow,  &c.,  but  in  neither  of  the  cases  can  these 
causes  act  but  indirectly — or,  in  other  words,  they  never  directly 
produce  that  peculiar  condition  of  the  nervous  system  which  is 
essential  to  the  existence  of  hysteria. 

The  third  set  of  causes  may,  and  we  believe,  sometimes  does, 
occasion  convulsions,  and  though  every  hysterical  paroxysm  is 
attended  with  convulsions,  yet,  every  convulsive  motion  of  the 
body  is  not  an  hysterical  paroxysm.  When  the  hysterical  pre- 
disposition exists,  any  severe  and  exhausting  discharge  may  oc- 
casionally produce  the  hysterical  paroxysm ;  but  not  always,  as 
the  following  case  will  show. 

Mrs. ,  from  an  early  period  of  her  life  was  subject,  from 

even  slight  causes,  to  severe  hysterical  paroxysms.  During  her 
pregnancies  she  was  often  attacked  by  this  affection,  and  was 
relieved  by  the  common  remedies.  In  one  instance  she  had  a 
paroxysm  during  labour,  but  it  neither  deranged  the  economy  of 
this  process,  nor  required  any  particular  treatment.  After  the 

1  Works,  p.  551. 

4  We  would  rather  call  them  predisposing  causes. 

1  We  do  not  mean  by  this  to  deny  that  the  constituent  portions  of  the  blood 
may  not  be  variously  modified,  and  give  rise  to  various  phenomena,  symptoms, 
or  even  active  or  chronic  disease.  We  only  object  to  the  assumption  of  a  super- 
added  something  as  a  cause  of  hysteria. 


470  HYSTERIA. 

birth  of  the  child,  she  was  attacked  with  a  violent  and  exhausting 
flooding,  from  which  she  was  relieved  only  by  the  most  active 
treatment.  She  continued  very  feeble  for  several  months ;  but 
during  which  time  she  had  no  hysterical  paroxysm ;  nor  did  any 
occur  until  she  again  recovered  her  usual  health. 

SECT.  II. — Of  the  Exciting  Causes. 

.•L    ,,     .  •!»**•••     »i      r\f -.  r<  i      •!«»'•     ivX  *       *V«i-T    •         '    * 

The  liability  to  attacks  of  hysterical  paroxysms  is  very  various 
in  different  individuals;  while  some  have  them  provoked  by  the 
slightest  causes,  others  require  that  they  shall  be  either  powerful, 
or  long-continued.  Instances  have  fallen  under  our  observation, 
where  the  most  trifling  alarm,  the  smallest  disappointment,  or 
the  slightest  provocation,  would  almost  instantly  produce  a  "  fit " 
of  longer  or  shorter  duration,  or  of  greater  or  less  violence ; 
while,  on  the  other  hand,  we  have  known  it  require  the  most 
powerful  of  the  exciting  causes  to  give  rise  to  them. 

They  all,  however,  seem  to  act  through  the  medium  of  the 
sensorium  commune;  at  least  this  would  seem  to  be  the  case  with 
genuine  hysteria;  and  may  serve  to  distinguish  it  from  several 
affections  of  the  system  with  which  it  is  almost  constantly  con- 
founded. Thus,  we  see  syncope,  from  exhaustion ;  from  peculiar 
odours;  from  pain;  from  nausea,  &c.,  confounded  with  hysteria, 
with  which,  perhaps,  it  has  no  necessary  connexion ;  though  it 
must  be  admitted,  that  the  hysterical  diathesis,  if  we  may  so 
term  it,  may  give  rise  to  syncope  in  certain  cases. 

Whytt1  enumerates  six  different  occasional  or  exciting  causes 
"of  nervous,  hypochondriacal,  and  hysterical  disorders,"  for  he 
confounds  them  under  one  consideration:  they  are  as  follow; 
namely: — 

1.  Wind,  VY.' 

2.  A  tough  phlegm,  Vin  the  stomach  and  bowels. 

3.  Worms,  J 

4.  Aliments  improper  in  their  quantity  or  quality. 

5.  Scirrhous  or  other  obstructions  in  the  viscera  of  the  lower 

belly. 

6.  Violent  affections  of  the  mind.2 

1  Works,  p.  570. 

1  To  these  may  be  added  "  the  inflammation  of  a  portion  of  the  spinal  column," 
agreeably  to  Mr.  Tate.  Since  reading  his  work  upon  this  subject,  we  have  been 
very  attentive  to  the  condition  of  the  spine  in  affections  generally  termed  nervous — 
but  the  result  of  the  examinations  we  have  made  differs  very  materially  from  those 
laid  down  as  constantly  obtaining  agreeably  to  Mr.  T.;  for  of  upwards  of  fifty 
spines  which  we  have  carefully  examined  agreeably  to  his  roles,  we  have  found  but 
three  cases  in  which  the  tenderness  which  he  describes,  in  some  portion  of  the  spine, 
was  sufficiently  obvious  to  make  us  resort  to  leeching,  cupping,  blistering,  or  ir- 
ritating it  with  the  tartar  emetic  ointment,  for  its  relief.  It  is,  however,  only  just 
to  say,  that  in  these  three  instances  the  plan  of  treatment  proved  successful. 


HYSTERIA.  471 

-!:*'-  '  f.-Mli.'jrtfflj  *;  • 

1,  2.    Wind  and  tough  Phlegm  in  the  Stomach  and  Bowels. 

One  of  the  most  common  symptoms  attendant  upon  nervous 
affections  is  the  elimination  of  air  in  the  stomach  and  bowels, 
when  these  parts  are  the  seats  of  sympathy:  but  this  phenome- 
non does  not  necessarily  attend  the  hysterical  diathesis;  for 
these  parts  do  not  necessarily  become  affected  by  the  prevalent 
disposition  or  diathesis ;  and  when  they  do  not,  the  extrication 
of  "gas"  will  not  take  place. 

But  should  the  stomach  and  bowels  be  involved  in  the  general 
diathesis,  these  parts  may  suffer  great  distention  from  flatulency. 
In  such  cases,  the  "wind  in  the  stomach  and  bowels"  is  but 
the  effect  of  a  certain  condition  of  these  parts,  and,  conse- 
quently, cannot  be  the  exciting  cause  of  hysteria,  or  any  other 
nervous  affection.  In  what  this  particular  condition  which  gives 
rise  to  the  extrication  of  "gas"  consists,  it  is  impossible  to  say; 
but  that  such  a  disposition  exists  is  notorious  to  every  body. 

This  condition  may  perhaps  consist  of  two  states  of  these  parts, 
altogether  different  from  each  other ;  one  is  said  to  be  occasioned 
by  relaxation,  which  suffers  them  to  be  distended  by  the  air  dis- 
engaged from  the  ingesta,  during  an  imperfect  digestion:  hence, 
a  "windy  stomach"  almost  always  attends  dyspepsia.  The 
Other  state  consists,  perhaps,  in  the  secretion,  or  elimination  of 
"gas"  from  the  extremities  of  the  vessels  terminating  upon  the 
internal  surface  of  the  stomach  and  intestines. 

We  believe  that  the  latter  circumstance  obtains  most  frequent- 
ly in  hysteria ;  the  former  is  most  common  in  dyspepsia;  yet  it  is 
possible  they  may  interchange.  It  is  now  some  years  since  the 
belief  of  the  "secretion  of  air"  in  various  parts  of  the  human, 
subject  was  suggested ;  (by  whom,  it  is  not  at  this  moment  recol- 
lected,) and  that  the  stomach  and  bowels  appear  to  be  more  ob- 
noxious to  it  than  any  other  parts  of  the  body.  This  secretion 
or  extrication  takes  place  under  certain  circumstances  indepen- 
dently of  any  permanent  loss  of  tone  in  these  parts ;  and  this  with 
a  suddenness  that  is  sometimes  truly  astonishing.  And  it  disap- 
pears sometimes  with  a  celerity  that  is  incredible.  The  follow- 
ing case  is  one  of  the  most  remarkable  we  have  met  with : — 

Mrs. ,  aged  twenty,  was  much  subject  to  hysteria  of  a  vio- 
lent kind,  whenever  her  mind  was  disagreeably  affected.  The 
manner  in  which  this  showed  itself  was  very  remarkable,  as  it 
seemed  to  be  almost  constantly  subject  to  metastasis ;  that  is,  after 
the  convulsive  action  had  continued  for  some  time,  it  would  sud- 
denly cease ;  she  would  regain  possession  of  her  senses,  and  would 
talk  rationally  upon  any  subject  that  might  present  itself.  This 
calm,  however,  would  last  but  a  short  time ;  for  she  would  now 
be  seized  with  the  most  violent  spasms  of  the  intestines,  and  of 


472  HYSTERIA. 

the  abdominal  muscles,  that  can  well  be  imagined ;  the  abdomi- 
nal muscles  would  be  drawn  backwards  with  such  force,  as  to 
make  the  belly  resemble  that  of  a  person  who  was  extremely 
emaciated;  when  of  a  sudden,  nay,  almost  in  the  twinkling  of  an 
eye,  it  would  become  distended  almost  to  bursting ;  in  this  man- 
ner these  conditions  would  alternate  with  each  other,  several 
times  in  the  course  of  a  few  minutes ;  then  an  interval  of  perhaps 
an  hour  or  two  might  take  place,  or  even  longer,  if  the  patient 
were  not  disturbed. 

There  was  a  strong  disposition  to  sleep,  whenever  the  pain 
would  abate  sufficiently  to  permit  it ;  and  this  would  be  enjoyed 
for  a  longer  or  shorter  period,  as  she  could  be  kept  more  or  less 
quiet.  rf Indeed,  the  paroxysm  would  almost  certainly  go  off,  if 
sleep  could  be  indulged  in,  undisturbedly;  but  which  was  a  mat- 
ter of  great  difficulty,  as  the  slightest  noise  would  awake  her ; 
and  the  instant  she  was  roused  the  spasms  would  return  with  ex- 
treme violence. 

The  distention  of  the  abdomen  was  sometimes  enormous:  full 
as  large  as  she  ever  was  at  the  last  period  of  utero-gestation ; 
yet  this  fulness  would  oftentimes  be  removed  in  almost  an  instant, 
without  our  understanding  in  what  manner  the  gas  was  disposed 
of.  It  was  certainly  not  discharged  by  either  mouth  or  anus  ; 
yet  it  was  certainly  dissipated  by  some  agency  or  other.1 

The  spasms  of  the  bowels,  and  the  production  of  gas,  would 
cease  sometimes  suddenly ;  the  patient  would  then  become  very 
drowsy,  nay,  for  awhile,  lethargic ;  but  from  which  she  would 
generally  awake,  after  a  longer  or  shorter  time,  perfectly  well. 
At  other  times,  when  the  brain  would  become  more  powerfully 
assailed,  she  would  have  the  appearance  of  apoplexy ;  the  breath- 
ing would  be  laborious,  and  even  stertorous;  the  cheeks  and  lips 
livid;  convulsive  twitchings  of  the  muscles  of  the  face;  the  skin 
cold  and  clammy,  and  the  pulse  depressed.  Nothing  relieved 
this  state  of  the  system  but  large  blood-lettings  ;  and  these  never 
failed  when  they  were  carried  to  a  sufficient  extent:  indeed,  the 
only  rule  we  observed  in  drawing  blood  was  to  continue  the  ab- 
straction of  it  until  there  was  an  abatement  of  these  threaten- 
ing symptoms. 

I  do  not  recollect  a  single  instance  of  failure  when  the  blood 
was  freely  abstracted ;  it  has  occurred  that  this  operation  was  re- 
peated; but  this  was  constantly  owing  to  too  small  a  quantity 
being  taken  at  first.  These  paroxysms,  of  cerebral  determination, 
were  sometimes  more  easily  relieved  than  at  others ;  that  is,  the 
loss  of  much  less  blood  would  answer  at  one  time  than  at  another. 

1  We  do  not  wish  to  be  understood  to  say  that  it  never  passed  by  the  mouth, 
for  it  certainly  did  so  occasionally — but  it  was  rare:  yet  when  it  did,  it  was  in 
such  a  continuous  torrent  as  to  suspend  respiration  so  long  as  to  threaten  suffoca- 
tion. 


HYSTERIA.  473 

The  loss  of  twenty  or  five-and-twenty  ounces  would  answer 
sometimes,  but  it  might  require  forty  upon  another  occasion. 

While  the  affection  was  confined  to  the  stomach  and  bowels, 
nothing  could  exceed  the  severity  of  suffering;  nor  was  it  ever 
controlled  by  any  of  the  usual  remedies  for  such  affections.  Im- 
mense doses  of  anodyne,  and  antispasmodic  medicines  were  given 
without  the  slightest  abatement  of  pain;  but  an  emetic  of  ipe- 
cacuanha would  almost  immediately  put  an  end  to  the  spasms. 

From  the  uniform  relief  procured  by  emetics,  it  might  be  sup- 
posed the  symptoms  arose  from  some  undigested  substance  in 
the  stomach;  but  this  was  not  the  case;  for  the  emetic  did  not 
bring  off  the  remains  of  food  previously  taken,  in  a  single  in- 
stance— the  discharge  would  consist  of  a  small  quantity  of  a  thin 
watery  substance,  of  an  acid  smell.  I  do  not  think,  in  any  in- 
stance, that  the  quantity  thrown  up  would  exceed  a  pint ;  but  no 
sooner  was  this  discharged  than  the  patient  would  be  relieved  al- 
together, or  have  but  slight  and  distant  returns  of  pain. 

In  this  case  the  obvious  remedy  was  an  emetic ;  and  this  was 
constantly  proposed ;  but  singular  to  say,  that  notwithstanding 
the  uniform  and  sudden  relief  procured  by  it,  notwithstanding 
the  employment  of  it  was  importunately  urged  in  the  commence- 
ment of  the  affection,  its  use  was  resisted  with  a  pertinacity  that 
could  not  be  overcome  by  long-continued  and  severe  suffering. 

Sometimes  this  remedy  was  resisted  until  the  disease  shifted 
its  ground,  and  the  head  would  become  the  seat  of  the  metastasis : 
when  this  took  place,  blood-letting,  as  just  remarked,  was  the 
only  remedy.  After  bleeding,  it  was  not  unusual  to  find  this 
hysterical  paroxysm  terminate  by  a  violent  gush  of  tears,  or  by 
obstreperous  laughter,  and  an  immense  flow  of  perfectly  limpid 
urine. 

It  has  been  remarked,  that  during  the  sleepy  state  of  this  dis- 
ease, the  patient  was  easily  roused ;  indeed,  a  morbid  sensibility 
of  the  ear  seemed  to  be  always  present:  a  person  speaking  even 
below  the  ordinary  tone  of  voice;  the  moving  of  a  chair,  how- 
ever cautiously ;  the  fall  of  the  smallest  body  upon  the  floor, 
which  would  scarcely  be  noticed  by  those  around,  would  rouse 
her  with  alarm,  and  renew  the  spasms.  These  would  continue 
sometimes  for  half  an  hour  with  much  severity ;  they  would  then 
either  abate,  or  she  become  so  overpowered  by  drowsiness,  that 
she  would  again  relapse  into  sleep,  from  which  she  might  again 
be  disturbed  by  the  slightest  noise.  In  this  way  she  would  con- 
tinue alternately  sleeping  and  suffering,  from  twenty-four  to  eight 
and  forty  hours ;  or  until  the  paroxysms  seemed  to  wear  them- 
selves out  or  were  interrupted  by  an  emetic,  or  by  a  large  blood- 
letting. I  never  knew  the  spasms  to  return  after  they  had  been 
translated  from  the  stomach  and  bowels  to  the  brain,  and  then 
producing  the  apoplectic  condition  just  mentioned;  for,  under 


474  HYSTERIA. 

this  form  it  was  always  found  necessary  to  bleed ;  and  this  never 
failed  to  relieve. 

But,  when  merely  heavy  sleepiness  was  produced,  they  would 
be  very  frequently  renewed,  as  just  stated;  unless  she  could  be 
kept  perfectly  silent,  which  was  next  to  an  impossibility,  owing 
to  the  slightness  of  the  noise  that  would  disturb  her. 

It  is  very  common  for  the  stomach  to  eructate  a  great  deal  of 
"gas,"  at  the  termination  of  an  hysterical  paroxysm,  from  which 
the  patient  finds  much  relief.  In  consequence  of  this,  it  has  been 
supposed,  that  "wind"  pent  in  the  stomach  was  the  exciting 
cause  of  the  hysterical  paroxysm ;  whereas,  it  is  only  a  conse- 
quence. For  this  "wind  "  from  the  stomach  takes  place  some- 
times where  there  is  not  a  dyspeptic  state  of  the  stomach.  Dr. 
Cullen1  corroborates  this  by  saying,  "  Persons  liable  to  hysteria 
are  sometimes  affected  at  the  same  time  with  dyspepsia."  They 
are  often,  however,  entirely  free  from  it. 

The  relief  obtained  in  such  cases  is  in  two  ways ;  first,  the 
paroxysm  terminates,  (most  probably,)  by  the  vessels  of  the  sto- 
mach pouring  out  "gas;"  as  inflammation  is  often  relieved  by 
the  vessels  concerned  pouring  out  serum.  It  may  also  be  re- 
lieved in  some  cases,  by  the  vessels  freeing  themselves  of  serum, 
and  this,  perhaps,  of  a  particular  quality.  Whytt  has  recognised 
"  a  tough  phlegm"  in  the  stomach,  as  noticed  above,  as  an  "oc- 
casional cause"  of  hysteria:  we,  however,  only  contend  for  its 
presence,  and  its  being  the  effect  of  a  paroxysm.  In  the  case 
above  related,  immediate  relief  was  constantly  experienced  if  an 
emetic  were  given ;  yet  the  emetic  never  did  more  than  bring  off 
a  quantity  of  fluid  mucus,  of  an  acid  smell.2  The  emetics,  in 
these  instances,  most  probably  hastened,  or  aided  the  vessels  to 
relieve  themselves.  For  certain  it  is,  this  fluid  could  not  be  the 
cause,  since  it  was  not  always  evacuated ;  for  an  emetic  was  not 
always  exhibited.  And  when  the  brain  took  up  the  wrong  ac- 
tion, the  paroxysm  was  sure  to  be  terminated  by  blood-letting. 

The  second  mode  of  relief  is  by  the  removal  of  the  painful 
distention  of  the  stomach  ;  for  this  organ  suffers  extremely  some- 
times from  "wind"  confined  in  it;  as  we  see  when  "gas"  is 
extricated  from  food  over  which  it  has  not  sufficient  control. 
The  precise  nature  of  the  "gas"  eliminated  in  such  cases,  from 
the  extreme  internal,  or  surface  vessels  of  the  stomach,  is,  per- 

1  First  Lines,  vol.  ii.  p.  2£6,  par.  1519. 

"  It  seems  that  hysteria  is  not  the  only  disease  classed  under  the  nervous  that 
experiences  relief  from  the  discharge  of  viscid  matter.  Wbytt  relates  the  case  of 
"a  girl  aged  fourteen  years,  who  had  been  troubled  with  chorea  sancti  viti,  who 
was  seized  with  measles.  A  few  days  after  her  recovery  she  had  a  return  of  her 
former  distemper,  which,  after  it  had  continued  a  fortnight  with  little  abatement, 
notwithstanding  the  use  of  several  remedies,  was  entirely  removed  in  n  few  days 
by  a  natural  looseness,  by  which  she  voided  a  great  deal  of  slimy  stuff." 


HYSTERIA.  475 

haps,  at  present  impossible  to  say,  as  we  do  not  know  that  any 
experiments  have  been  made  to  ascertain  it. 

In  the  case  of  the  lady  above  related,  when  the  wind  was  dis- 
charged by  the  mouth,  it  would  pass  in  so  continuous  a  stream 
as  to  suspend  respiration  for  a  considerable  time;  and  the  quan- 
tity disengaged  was  so  enormous  as  to  justify  us  in  setting  it 
down  at  several  galtons.  We  witnessed  several  instances  of  the 
escape  of  this  "gas :"  it  had  no  taste  to  the  lady,  nor  had  it  smell 
to  the  by-standers.  In  this  latter  respect,  it  certainly  differed 
from  the  air  disengaged  during  the  process  of  an  imperfect  di- 
gestion; for  the  "gas"  belched  by  dyspeptic  patients  smells 
and  tastes  almost  always  of  the  food  from  which  it  is  liberated. 


3,    Worm». 

Worms  in  the  intestinal  canal  will  produce,  as  is  well  known, 
a  great  variety  of  formidable  symptoms,  especially  in  children ; 
such  as  great  appetite,  distention  of  the  abdomen,  cough,  vomit- 
ing, tremors,  convulsions,  &c.;  but  such  symptoms  should  not 
be  considered  as  hysterical.  For  these  events  take  place  almost 
always  before  the  hysterical  diathesis  is  generated;  nor  do  they, 
perhaps,  require  any  particular  condition  of  the  system,  like  hys- 
teria, to  have  them  produced:  it  is  sufficient  that  these  animals 
irritate  the  intestines  to  a  certain  extent,  to  have  the  above  train 
of  symptoms,  and  sometimes  many  more,  to  present  themselves. 

At  a  period  of  life  beyond  that  of  childhood,  these  vermin  may 
prove  the  exciting  cause  of  an  hysterical  paroxysm  where  this 
diathesis  exists ;  or  they  may  be  even  the  remote  cause  of  this 
condition  of  the  system.  We  have  witnessed,  in  a  lady,  violent 
attacks  of  hysterical  "fits,"  from  the  presence  of  a  tape  worm; 
which  continued  pretty  regular  in  their  attacks  for  several  years. 
The  following  relation  of  the  case  may  not  be  unacceptable. 

Mrs. ,  the  mother  of  several  children,  and  generally  en- 
joying good  health,  though  of  a  nervous  temperament,  was  seized, 
about  the  beginning  of  the  year  1821,  with  a  variety  of  nervous 
symptoms;  such  as  palpitations  of  the  heart;  globus  hystericus  ; 
disposition  to  cry,  from  very  slight,  or  even  no  apparent  cause ; 
vertigo;  ringing  in  the  ears;  headach;  and  large  discharges  of 
pale  urine.  She  took  a  variety  of  remedies  for  these  affections, 
by  the  advice  of  her  mother,  and  other  friends,  with  temporary 
advantage.  But  it  was  found  that  each  of  these  symptoms  in- 
creased in  force  as  well  as  frequency,  and  from  slighter  causes 
than  before ;  and,  at  length,  a  regular  hysterical  paroxysm,  of 
great  violence,  was  produced. 

During  a  paroxysm  she  was  bled,  took  asafoetida,  laudanum, 


476  HYSTERIA. 

&c.,  and  was,  after  a  few  hours,  restored  to  her  usual  health, 
which  was  still  pretty  good,  though  evidently  on  the  decline,  not- 
withstanding the  employment  of  a  number  of  "  certain  cures,"  for 
her  complaint.  The  "  fits  "  were  now  repeated  from  time  to  time, 
but  each  succeeding  one  appeared  to  acquire  an  increase  of  force 
and  duration.  Her  appetite  and  strength  now  failed  rapidly ; 
she  vomited  a  glairy  tenacious  substance  almost  every  morning, 
which  was  without  taste:  severe  pains  in  the  abdomen,  especially 
on  the  left  side;  her  rest  was  much  disturbed;  almost  constant 
headache,  &c. 

The  "fits"  now  bore  a  stronger  resemblance  to  epilepsy  than 
to  hysteria,  that  is ;  she  would  be  seized,  while  walking  the  floor, 
with  only  an  instant  of  warning;  whereas,  formerly,  the  "  con- 
vulsion" would  be  preceded  by  the  usual  premonitions  of  hys- 
teria. There  was  less  struggle  during  the  paroxysm,  and  some 
frothing  at  the  mouth ;  but  the  duration  was  much  shortened. 
She  would,  however,  remain  very  feeble  for  several  days  after 
each  attack;  and  be  assailed  by  the  feelings  common  to  nervous 
affections. 

The  progress  and  changes  stated  above  occupied  a  period  of 
about  three  years:  the  "fits"  now  returned  every  three,  four,  or 
five  weeks,  without  any  apparent  exciting  cause;  but  these  pe- 
riods would  be  occasionally  anticipated,  when  her  mind  was  af- 
fected by  any  unlooked-for  occurrence  of  a  disagreeable  kind. 
About  this  time  she  was  advised  by  some  friend  to  try  strong  salt 
and  water,  in  pint  doses,  every  morning,  for  nine  mornings,  for 
it  was  now  believed  she  had  a  tape  worm.  She  did  so  most  per- 
severingly,  notwithstanding  the  severe  effect  it  produced  on  her 
stomach  and  bowels ;  and  she  was  amply  rewarded  for  her  reso- 
lution', by  the  discharge  of  a  portion  of  a  tape  worm,  seven  yards 
in  length,  as  was  supposed,  for  it  was  not  measured.  Her  health 
improved  very  much  after  this,  though  occasionally  subject  to 
slight  hysterical  paroxysms,  but  nothing  like  so  frequent  or  so 
severe.  She  has  had  but  two  for  the  last  eighteen  months,  and 
these  were  light.  She  has  since  borne  a  fine  healthy  child,  after 
an  interval  of  seven  years. 

:  £oiv;'  ?'  ,'  «.•'  '•  i  i  fr  '.K»  fcCK.i?«tftqfi  •'<•;:  ;{''ff»:  ,"  £••;*:•*  7  LI  '  - 

;  c*:yj/>  ^r'Ytrrf^a  oo  nvrj  •!<•  ,'.i!j;il>  VH*  m-sit  /rv>  CM  iviijie-.q*;." 

4.  Aliments  improper  in  their  Quantity  or  Quality. 

Almost  every  body  has  experienced  the  truth  of  the  old  pro- 
verb, that  "what  is  one  man's  meat  is  another's  poison;"  and 
consequently,  it  will  be  ever  found  difficult  to  regulate  diet  by  any 
prescribed  quantity,  or  any  particular  quality,  for  they  must  be 
looked  upon  as  relative  terms.  Nothing  can  exceed  the  variety 
of  dispositions  (if  we  may  so  term  it)  in  the  human  stomach ;  it  is 
capricious  at  times,  in  the  extreme,  while  at  others  it  will  suffer 


HYSTERIA.  477 

great  abuses,  and  this  for  a  long  time,  without  resistance  or  com- 
plaint. Experience  alone,  in  many  instances,  is  the  only  safe 
guide  by  which  the  food,  in  either  quantity  or  quality,  can  be 
regulated  in  nervous  and  dyspeptic  patients. 

It  is  therefore  not  to  surprise  us,  that  directions  for  the  use 
of  food  in  such  constitutions  will  often  prove  successful,  if  not 
improper ;  hence,  nothing  is  more  common  than  peculiarities  in 
the  digestive  process.  Indeed  the  same  article,  and  in  the  usual 
quantity,  will  sometimes  fail  to  be  digested,  though  it  may  gene- 
rally prove  very  grateful  to  the  stomach;  for  should  this  organ 
be  in  a  state  of  sympathy,  or  of  nervous  excitement,  the  most 
familiar  and  commonly  acceptable  food  may  prove  the  exciting 
cause  of  an  hysterical  paroxysm.  For  this  reason  we  should 
never  fail  to  inquire  whether  any  thing  unusual  has  been  taken 
into  tho  stomach,  when  about  to  prescribe  for  an  hysterical  pa- 
roxysm. 

I  knew  a  lady  subject  to  hysteria,  who  could  tell  by  her  feel- 
ings two  or  three  days  before,  that  she  was  about  to  have  an  at- 
tack.1 When  under  this  impression  she  was  obliged  to  be  very 
careful  in  the  government  of  her  mind,  as  well  as  cautious  in  her 
diet,  for  as  certainly  as  the  one  was  unpleasantly  excited,  or  the 
other  neglected,  she  would  have  an  hysterical  paroxysm.  While, 
on  the  other  hand,  if  she  was  successful  in  avoiding  mental  ex- 
citement, and  did  not  over-tax  her  stomach,  she  would  generally 
avoid  the  "fit."  But  it  must  be  remarked,  though  she  avoided 
a  paroxysm,  she  was  sure  to  be  inconvenienced  by  headache  for 
several  days. 


5.  Seirrhom  or  other  Obstructions  in  the  Stomach,  Intestines,  $c. 

Whytt2  has  taken  some  pains  to  establish  the  opinion,  that 
scirrhous  affections  of  almost  any  of  the  abdominal  viscera  will 
occasion  nervous,  hypochondriacal,  and  hysterical  affections. 
He  has  given  several  histories  of  cases,  with  dissections,  but 
neither  of  which  proves  the  point  at  issue,  for  there  is  no  evi- 
dence whatever  that  the  affections  developed  by  the  knife,  gave 
rise  to  the  few  nervous  symptoms  detailed  in  these  cases.  At 
all  events  there  was  no  hysteria  produced;  hypochondriasis  may 
have  been ;  since  the  stomach  in  almost  every  case  was  much 
diseased. 

1  The  hysterical  paroxysms  in  this  lady  were  periodical ;  the  attacks  though  se- 
vere, were  by  no  means  frequent,  yet  she  rarely  had  an  attack  without  a  warning 
of  two  or  three  days;  or,  in  other  words,  she  had  occasionally  certain  feelings, 
which  she  knew  would  terminate  in  an  hysterical  "  fit,"  if  she  did  not  studiously 
avoid  exciting  causes. 

1  Works,  p.  575. 


478  HYSTERIA. 

So  far  as  our  own  observations  have  extended,  we  have  had 
no  reason  to  suspect  hysteria  to  be  produced  by  derangements 
in  any  of  the  chylopoietic  viscera  ;  these  derangements,  however, 
may,  and  perhaps  do,  augment  the  paroxysms,  or  they  may  per- 
petuate the  disposition,  by  preventing  the  return  of  healthy  action 
in  the  system,  but  there  is  strong  reason  to"  doubt  of  their  being 
the  remote  cause  of  this  affection. 

We  have  repeatedly  seen  great  derangements  in  the  liver, 
spleen,  stomach,  intestines,  and  even  the  uterus  itself,  where 
there  was  the  most  entire  exemption  from  hysteria.  We  do  not, 
however,  mean  to  insinuate  that  these  two  conditions  may  not 
exist  in  the  same  person  ;  we  wish  merely  to  deny  that  these  ob- 
structions in  themselves  are  causes  of  hysteria. 


6,  Violent  Affections  qf  the  Mind. 

lsk>  one  can  for  a  moment  hesitate  to  acknowledge  the  influence 
of  the  mind  upon  the  nervous  system.  Passions  and  emotions 
may  not  only  prove  the  exciting,  but  they  may  also  serve  as  the 
remote  causes  of  hysteria.  The  experience  of  almost  every  body 
can  furnish  illustrations  of  these  facts,  and  medical  records  abound 
with  remarkable  examples  of  them.  They  must,  therefore,  be 
admitted  as  such,  though  we  cannot  pretend  to  explain  by  what 
agency  or  by  what  change  it  is  effected.  Through  the  medium 
of  each  sense,1  hysteria  has  been  produced,  if  we  credit  writers 
upon  the  subject;  nor  does  it  require  much  credulity  to  believe 
them  from  what  we  constantly  witness  from  a  part  of  them. 

I  have  a  patient  in  whom  the  globus  hystericus  can  be  excited 
instantly,  if  she  smell  camphor.  This  peculiarity  took  its  rise 
from  a  strong  aversion  being  excited  from  having  taken  large 
quantities  of  it  in  a  fit  of  severe  illness.  I  know  another,  who 
has  become  a  severe  sufferer  from  hysteria  from  having  taken 
an  excessive  dose  of  it  by  mistake.  It  produced  mania  at  first, 
which  continued  for  nearly  three  months.  Before  this  accident, 
she  had  never  betrayed  the  slightest  disposition  to  any  nervous 
affection. 

Thus  hysterical  paroxysms  have  been  produced  by  seeing 
others  afflicted  with  it.  The  most'  remarkable  instance  of  this 
kind  is  the  one  related  by  Kaau  Boerhaave,2  as  having  happened 

1  With  the  exception  perhaps  of  the  sense  of  taste,  I  have  never  met  with  an 
instance  of  hysteria  produced  by  disgust  to  the  palate. 

*  Kaau  Boerhaave,  the  nephew  of  the  celebrated  Boerhaave,  relates  an  occur- 
rence of  a  very  remarkable  kind,  as  having  taken  place  at  the  Harlaem  hospital. 
A  girl  was  brought  into  the  ward  in  convulsions  of  a  periodical  kind  ;  the  convul- 
sion was  repeated  the  next  day,  which  affected  several  who  beheld  her  in  the  same 


HYSTERIA.  479 

at  the  podr-house  at  Harlaem.  The  disease,  in  the  first  place,  was 
excited  by  the  operation  of  terror  upon  the  sensoriurn  commune, 
and  it  was  arrested  by  a  terror  of  a  more  violent  kind,  through 
the  same  medium.  I  knew  a  lady  who  would  be  thrown  into  an 
hysterical  paroxysm  by  the  sudden  report  of  a  gun.  Certain 
odours,  as  noticed  above,  have  been  known  to  do  the  same,  at 
least  to  produce  fainting.  I  once  saw  a  lady  thrown  into  a  se- 
vere "fit"  by  placing  her  hand  accidentally  upon  the  back  of  a 
cat,  for  which  animal  she  had  a  great  aversion. 


SECT.  III. — Of  the  Phenomena  of  Hysteria. 

When  a  predisposition  to  hysteria  exists,  or  the  disease  has 
been  once  called  into  activity,  a  great  variety  of  causes  may  ex- 
cite a  paroxysm  of  greater  or  less  force.  An  hysterical  parox- 
ysm, properly  so  called,  is  where  the  system  is  thrown  into  that 
violent  agitation  called  "  a  fit  of  hysterics."  A  vast  variety  of 
symptoms  may  from  time  to  time  manifest  themselves,  such  as 
palpitation  of  the  heart,  globus  hystericus,  large  flow  of  limpid 
urine,  rumbling  of  wind  in  the  bowels,  belchings,  acid  stomach, 
whimsical  appetite,  tremblings,  cold  feet  and  hands,  &c. ;  but 
these  are  termed  nervous  symptoms.1 

V 

manner,  and,  in  a  few  days  more,  all  were  affected  who  were  in  the  same  ward, 
whether  they  were  girls  or  boys.  This  became  so  general  as  to  excite  great  alarm; 
every  means  which  experience  had  found  useful  hitherto  in  such  affections,  were 
Tried  in  vain.  They  at  length,  sent  for  Boerhaave  himself.  He  directed  that  a 
variety  of  iron  implements  should  be  heated  red  hot  in  a  furnace  in  the  ward,  and 
be  in  readiness  at  the  time  these  convulsions  were  wont  to  make  their  appearance; 
and  ordered,  that  the  first  one  that  was  seized  with  the  disease,  should  be  burnt 
on  the  arm,  with  a  heated  iron,  to  the  bone.  This  so  alarmed  the  subjects  of 
this  affection,  that  in  an  instant  a  stop  was  put  to  the  complaint. 

1  Mr.  Tate,  (Treatise  on  Hysteria,  p.  39,)  says,  "The  next  circumstance,  and 
the  most  important  of  the  whole  list,  whether  as  regards  the  discrimination  of  the 
disorder,  or  its  treatment,  is  this — that  in  every  case  there  is  a  distinct  pain  upon 
the  application  of  pressure  or  of  heat,  to  three  or  four  of  the  six  superior  dorsal 
vertebrae.  This  is  a  point  upon  which  I  desire  to  fix  the  reader's  attention;  for 
this  spinal  affection,  whatever  its  intrinsic  quality,  is  clearly  chargeable  with  most 
of  the  curious  images  and  fantastic  forms  that  hysteria  is  accustomed  to  put  on; 
and  yet,  notwithstanding  its  constant  occurrence  in  those  forms  of  hysteria,  and 
its  frequent  existence  where  there  is  even  a  tendency  to  hysteric  disorder,  it  is  a 
circumstance  that  has  been  overlooked  by  those  who  have  professed  to  treat  upon 
this  subject,  as  well  as  those  who,  for  the  sake  of  gratifying  curiosity,  have  pub- 
lished detached  cases  of  hysteria  under  various  other  designations." 

We  confess  this  condition  of  the  dorsal  vertebras  to  be,  in  this  disease,  new  to 
MS;  and  it  may  become  an  important  item  in  diagnosis,  if  future  observations  con- 
firm it.  We,  however,  must  declare,  that  up  to  this  period  we  cannot.  If  pres- 
sure be  made  upon  the  dorsal  vertebras  when  in  this  pathological  condition,  it  not 
only  excites  pain  in  the  part,  but  in  other  parts  very  often,  as  through  the  chest, 
left  side,  or  sometimes  both,  and  generally  oppresses  the  breathing. 

Mr.  Tate  says  this  pain  is  not  always  equally  severe;  sometimes  the  vertebrae 
are  very  tender,  at  others  they  are  less  so,  depending,  he  thinks,  upon  the  force 
of  the  affection,  but  it  is  always  present  in  a  greater  or  less  degree. 


480  HYSTERIA. 

Sometimes  the  paroxysm  comes  on  very  suddenly,  and  is  in 
full  force  in  an  instant ;  at  others,  there  will  be  a  number  of  symp- 
toms which  announce  the  fit  to  be  at  hand,  such  as  headache,  of 
a  piercing  kind:  oppression  about  the  prsecordia;  heaving  of  the 
chest;  difficulty  of  breathing;  alternate  laughing  and  crying,  &c. 
All  these  symptoms,  however,  may  exist  without  being  followed 
by  a  "fit;"  but  when  they  are  present,  it  is  always  to  be  appre- 
hended, especially  when  crying  or  laughing  be  of  the  number. 

Laughing  and  crying  are  among  the  most  remarkable  symp- 
toms of  hysteria — they  may  alternate  with  each  other,  or  they 
may  exist  separately ;  but  whether  combined,  or  alternate,  they 
are  almost  always  accompanied  by  an  alienation  of  mind,  which 
discovers  itself  by  a  rapid,  incoherent,  or  desultory  talking ;  and 
constantly  dwelling  upon  the  cause  of  their  indisposition,  if  the 
exciting  cause  has  been  of  the  moral  kind.  At  other  times,  the 
patient  employs  herself  in  singing  melancholy  or  lugubrious  airs. 
I  have  seen  this^last  circumstance  produce  a  wonderful  effect 
upon  the  attendants  of  the  patient.  I  knew  a  lady  who  sang 
most  sweetly  at  all  times;  but  when  under  an  hysterical  parox- 
ysm, her  voice,  manner,  and  the  subjects  of  her  songs,  were  so 
touching  as  to  dissolve  all  those  around  her  into  tears. 

An  "hysterical  fit,"  when  violent,  is  extremely  awful;  the 
violent  and  varied  contortions  of  the  body  would  seem  to  threaten 
dislocation  of  every  joint ;  while  the  swollen  face,  the  protruded 
tongue,  the  staring  eyes,  the  gnashing  teeth,  the  appalling  scream, 
render  the  whole  scene  one  of  great  horror.  Sometimes  the 
hair  is  deracinated  by  handfuls;  the  chest  is  beaten  by  the 
clenched  fist,  with  threatening  violence ;  while  the  whole  muscular 
system,  when  thrown  into  action,  is  endowed  with  a  strength 
that  bids  defiance  to  all  attempts  at  restraint. 

The  sphincter  ani,  like  the  other  muscles  of  the  body,  partici- 
pates in  this  unnatural  state  of  action ;  for  it  is  found  contracted 
so  firmly  sometimes,  as  to  prevent  the  introduction  of  the  pipe 
of  a  small  syringe.1  The  abdominal  muscles  also  are  violently 
contracted  sometimes  during  the  fit,  and  especially  about  its 
central  portion,  the  navel. 

Dr.  Cullen  says,  and  it  entirely  agrees  with  our  experience, 
that  this  disease  "more  especially  affects  the  females  of  the  most 
exquisitely  sanguine  and  plethoric  habits,  and  frequently  affects 
those  of  the  most  robust  and  masculine  constitution;  but  it  is 
not  confined  to  such  ;  for  the  nervous  and  irritable  are  also  liable 
to  this  affection.  By  the  nervous  and  irritable  we  understand, 
such  constitutions  as  are  affected,  or  easily  moved,  by  slight  ex- 
citing causes.  This  condition  of  the  system  may  be  either  con- 
stitutional or  acquired.  Improper  physical  education  will  render 

1  Cullen. 


HYSTERIA.  481 

almost  any  constitution  nervous  or  irritable,  if  it  be  continued 
sufficiently  long;  hence,  those  who  indulge  in  habits  of  idleness, 
too  high  living,  lying  in  bed  too  much,  night  watching,  &c.  &c., 
are  almost  sure  to  possess  this  peculiarity ;  or  this  peculiar  con- 
dition may  exist  as  an  original  state  of  stamina.1 

Under  such  circumstances,  hysteria  will  almost  certainly  be 
generated,  if  the  exciting  causes  be  applied ;  and  hence  it  is,  that 
delicate  females  are  more  liable  to  it  than  robust  women  or  men ; 
and  hence  women  of  this  constitution  are  almost  sure  to  be  af- 
fected with  nervous  tremblings,  palpitation  of  the  heart,  syn- 
cope, &c. ;  though  otherwise  enjoying  very  good  health.  In 
such,  also,  may  readily  be  excited  hysterical  paroxysms,  or  con- 
vulsions ;  for  either  the  active  passions,  or  emotions  of  the  mind, 
as  anger,  revenge,  jealousy,  and  even  surprise;  or  the  passive 
ones,  as  fear,  grief,  or  disappointed  hope,  will  oftentimes,  in  a 
moment,  have  this  effect. 

Disease  may  produce  this  state  of  the  nervous  system  in  con- 
stitutions not  previously  disposed  to  this  condition ;  hence,  we 
sometimes  see  hysteria  follow  recoveries  from  long-protracted 
illnesses  ^especially  in  females.  In  such  cases,  there  does  not 
appear  to  be  any  increase  of  nervous  sensibility ;  it  is  rather  an 
altered  condition  of  the  nervous  system ;  as  it  now  becomes  ob- 
noxious to  causes  which  would  not  previously  have  affected 
them.  Hence,  the  wonderful  effects  of  certain  odours,  medi- 
cines, or  even  sounds,  in  such  a  condition  of  nervous  peculiarity. 
I  have  known  two  or  three  instances  where  the  smell  of  the  tube- 
rose, the  lily,  or  the  lilac,  has  been  followed  by  faintness  and 
palpitation  of  the  heart ;  though  previously  to  the  illness  they 
had  no  such  tendency.2  I  have  known  the  very  name  of  rhu- 
barb, and  of  the  Peruvian  bark,  excite  the  most  violent  disgust, 
and  sickness  of  stomach.  I  know  a  gentleman  who  cannot 

'  Mr.  Tate  mentions  another  symptom  which  he  thinks  goes  far  to  distinguish 
or  characterize  hysteria — it  is  an  acute  pain  in  the  left  side  just  below  the  left 
breast,  and  about  the  fifth  or  sixth  rib, — it  is  very  circumscribed  in  extent,  but  is 
extremely  acute.  This  affection,  as  one  of  the  characters  of  hysteria,  is  also  new 
to  us,  though  we  have  frequently  noticed  the  symptom.  In  one  or  two  instances 
it  has  been  of  great  severity,  but  in  neither  were  the  patients  subject  to  any  ob- 
vious form  of  hysteria.  In  both  of  the  cases  in  which  we  had  occasion  to  pre- 
scribe for  this  affection,  the  pain  was  constantly  removed  by  rubefacients  applied 
immediately  to  the  spot. 

Mr.  Tate  thinks  that  this  pain  has  frequently  produced  the  lateral  curvature  of 
the  spine,  as  it  is  sometimes  of  very  long  continuance,  and  the  patient  with  a  view 
to  its  relief  constantly  leans  towards  the  affected  side. 

*  Dr.  Whytt  details  several  similar  instances  from  this  kind  of  change  in  the 
nervous  system;  he  says,  "Thus,  several  delicate  women,  who  could  easily  bear 
the  stronger  smell  of  tobacco,  have  been  thrown  into  fits  by  musk,  ambergris,  or 
a  pale  rose."  "  The  smell  of  cheese  has  almost  always  occasioned  the  bleeding  of 
the  nose  in  some."1  Works,  p.  543. 

'  K  'au  Boeibaave. 

31 


482  HYSTERIA. 

drink  a  glass  of  any  of  the  -white  wines,  though  formerly  fond  of 
them,  in  consequence  of  having  frequently  been  puked  with  anti- 
monial  wine  during  a  tedious  fever.  Mr.  Boyle,  (Usefulness  of 
Experimental  Philosophy,)  tells  us  of  a  gentleman  who  could  be 
more  violently  puked  by  coffee  than  by  crocus  metallorum,  or 
other  strong  emetics ;  and  was  made  sick  constantly  by  its  smell ; 
though  he  formerly  drank  it  without  the  slightest  inconvenience. 
I  knew  a  lady,  after  recovery  from  a  protracted  typhus,  agonized 
by  the  sound  of  distant  thunder ;  she  was  less  affected  when  it 
was  near  and  violent.  And  Boyle,  (Usefulness  of  Experimental 
Philosophy,)  also  relates  the  case  of  a  lady,  who  upon  hearing 
the  sound  of  a  bell,  or  any  loud  noise,  would  swoon  so  deeply  as 
scarcely  to  be  distinguished  from  death. 

Those  who  have  the  misfortune  to  labour  under  this  idiosyn- 
cracy  of  nerve  are  peculiarly  unfortunate ;  as  they  are  constant- 
ly liable  to  be  affected  by  causes  which  have  not  the  slightest 
influence  on  others;  and  to  such  become,  but  too  often,  the  object 
of  cruel  and  ill-directed  ridicule.  Because  affections  of  this  kind 
do  not  often  kill;  and  because  the  subject  of  them  very  often  en- 
joys otherwise  very  good  health,  it  is  with  too  much  facility  sup- 
posed that  every  ill  of  which  they  complain  is  but  the  ima- 
ginings of  a  distempered  brain. 


SECT.  IV. — Diagnosis  of  Hysteria. 

Sydenham,  and  some  others,  think  the  analogy  between  hys- 
teria in  women,  and  hypochondriasis  in  men,  is  so  strong,  as  to 
consider  them  as  one  and  the  same  complaint;  but  this  is  cer- 
tainly not  the  case.  Hoffman  looks  upon  them  as  distinct  dis- 
eases; and  Cullen  strongly  inclines  to  the  same  opinion;  at  least 
he  arranges  them  under  different  genera.  He  places  hypochon- 
driasis in  the  class  of  Neurosis,  and  the  order  Adynamise;  and 
hysteria,  in  the  same  class,  under  the  order  Spasmi. 

It  is  not  a  little  surprising,  that  Sydenham,  one  so  proverbial 
for  accuracy,  should  have  confounded  these  diseases ;  especially 
as  their  respective  characters  are  pretty  strongly  marked.  1st. 
The  subjects  of  attack  are  by  no  means  the  same,  as  far  as  tem- 
perament will  constitute  a  difference ;  for  we  have  noticed  that 
hysteria  is  most  common  to  women,  and  those  of  a  sanguine  and 
plethoric  constitution ;  whereas,  hypochondriasis  has  more  fre- 
quently men  of  a  melancholy  temperament  for  its  objects.  2d. 
Hysteria  is  relieved  very  often  as  life  advances;  whereas  the 
other  is  almost  always  aggravated.  3d.  The  pathognomonics  of 
hysteria,  as  Dr.  Good  very  justly  observes,  such  as,  "the  con- 
vulsive struggling  paroxysms,  the  sense  of  a  suffocating  ball  in  the 
throat,  the  fickleness  of  temper,  and  the  copious  and  limpid  urine, 


HYSTERIA.  483 

have  no  necessary  connexion  with  hypochondriasis,  and  are 
never  found  in  this  disease,  when  strictly  simple  and  idiopathic. 
While,  on  the  contrary,  the  sad  and  sullen  countenance,  the  de- 
jected spirits,  and  gloomy  ideas,  that  characteristically  mark  hy- 
pochondriasis, have  as  little  necessary  connexion  with  hysteria, 
and  are  in  direct  opposition  to  its  ordinary  course."  Vol.  iii.  p. 
353.  An  attention  to  these  marks  will  serve  to  discriminate  the 
two  diseases  perfectly. 


SECT.  V. — Treatment. 

The  whole  history  of  hysteria  shows  that  the  nerves  of  certain 
parts  of  the  body  are  more  liable  than  others  to  that  particular 
state  which  gives  rise  to  its  phenomena ;  and  that  this  condition 
of  the  nervous  power  declares  itself  almost  always  in  certain  por- 
tions of  the  system.  This  condition  seems  to  have  an  election,  if 
we  may  so  term  it;  or,  in  other  words,  certain  parts  more  con- 
stantly sympathize  with  the  brain,  and  become  more  liable,  or 
more  easily  involved,  than  others. 

It  is  true,  Hoffman  locates  hysteria  in  the  stomach ;  nor  is  this 
difficult  to  understand;  since,  in  severe  stages  of  this  affection  the 
stomach  is  very  apt  to  be  deranged ;  but  this  is  only  the  effect  of 
this  certain  or  hysterical,  (if  we  may  so  term  it,)  condition  of  the 
brain.  For  there  have  been  many,  instances  of  hysteria,  and 
some  of  which  I  have  witnessed,  where  the  stomach  was  in  a 
most  perfect  state  of  health ;  and  I  have  seen  cases  of  great  de- 
rangement of  this  organ,  where  no  hysterical  symptoms  have  at- 
tended. 

Doubtless  the  stomach,  like  any  other  organ  of  the  body,  may 
be  a  seat  of  hysterical  sympathy :  in  this  case  we  shall  have  a  va- 
riety of  gastric  symptoms,  which  will  vary  in  force,  as  well  as  in 
character,  according  to  the  state  of  predisposition  and  power  of  the 
exciting  cause.  But  when  this  occurs,  the  nature  of  the  affection 
will  almost  always  betray  itself  by  the  presence  of  some  other 
symptoms  which  may  be  considered  as  pathognomonic  of  hyste- 
ria; such  as  palpitation  of  the  heart;  a  sense  of  coldness  on  the 
top  of  the  head;  an  increased  flow  of  urine,  &c.  But  should 
neither  of  these  symptoms  declare  itself,  we  are  pretty  certain 
that  the  gastric  affection  is  of  an  idiopathic  nature,  and  may  very 
often  be  justly  named  dyspeptic. 

The  same  observations  will  apply  when  the  derangement  shall 
be  in  the  bowels,  or  some  one  of  the  abdominal  viscera ;  hence, 
the  importance  of  attending  to  this  distinction,  in  all  affections  of 
these  parts.  For  when  this  organ  is  labouring  under  an  active 
malady,  as  inflammation,  there  is  for  the  most  part  an  exemption 
from  the  symptoms  constituting  hysteria;  consequently,  for  the 


HYSTEKIA. 

production  of  this,  a  peculiar  condition  of  the  nerves  of  the  part 
seems  to  be  always  required.  b^V---- 

On  the  presence  of  the  affections  just  alluded  to,  and  now  about 
to  be  more  particularly  mentioned,  we  may  almost  always  detect 
the  existence  of  this  condition  of  portions  of  the  nervous  system, 
and  determine  the  extent  of  their  agency,  either  in  modifying  or 
giving  rise  to  new  phenomena  in  the  other  systems  of  the  body. 
Thus,  palpitation  of  the  heart,  large  discharges  of  limpid  urine,  a 
ball  rising  in  the  throat,  a  sense  of  coldness  on  the  top,  or  back 
part  of  the  head,  with  a  disposition  to  cry  or  laugh,  will  always 
point  out  the  peculiar  disposition  of  the  nerves  concerned  in  the 
functions  of  the  various  parts  just  enumerated;  and  it  can  be 
pretty  certainly  determined  by  the  state  of  the  vascular  system, 
how  far  they  must  be  considered  as  the  cause  or  the  effect  of  ex- 
isting symptoms. 

In  a  practical  point  of  view,  an  attention  to  the  above  sugges- 
tions is  of  the  utmost  consequence — for  certainly  it  is  not  too 
much  to  affirm,  in  very  many  instances,  that  that  practice  cannot 
be  successful  which  throws  out  of  sight  this  condition  of  the  vas- 
cular system.  In  every  affection  of  the  body  the  state  of  the 
blood  vessels  should  constantly  be  kept  in  view ;  for  on  this  our 
success  will  very  much  depend,  when  treating  affections  in  which 
hysterical  phenomena  are  present;  for  it  will  almost  certainly 
point  out  whether  the  nervous  or  vascular  system  is  most  to  be 
attended  to,  and  in  what  succession. 

There  are  few  errors  more  common  in  practice,  than  that  of 
treating  nervous  symptoms  independently  of  the  circulatory  sys- 
tem; and  hence,  the  too  often  want  of  success  of  the  common 
remedies  when  administered  without  attention  being  paid  to  it. 
The  constant  belief,  that  blood-letting,  or  any  other  depletion,  is 
injurious  in  nervous  diseases,  has  very  often  prevented  the  suc- 
cess of  the  best  remedies ;  and  consequently,  has  caused  a  dis- 
ease to  be  protracted  and  obstinate,  which  would  have  yielded 
almost  instantly  to  the  common  agents,  had  their  administration 
been  preceded  by  the  loss  of  a  few  ounces  of  blood,  or  even,  per- 
haps, by  a  brisk  cathartic. 

However  ill  depletion  may  agree  with  nervous  constitutions 
under  a  want  of  excitement  in  the  vascular  system,  it  is  neverthe- 
less indispensable,  when  hysterical  symptoms  are  accompanied 
by  an  exalted  arterial  action ;  and  it  should  therefore  always  be 
premised.  Whoever  expects  to  be  successful  in  the  treatment  of 
nervous  patients  without  paying  attention  to  the  state  of  the 
pulse,  will  find  himself  constantly  disappointed;  and  the  applica- 
tion of  such  medicines  as  are  known  to  exert  an  influence  upon 
the  nervous  system,  will  be  sure  to  be  unsuccessful,  if  not  mis- 
chievous. 

Who  has  not  witnessed  the  want  of  success  of  opium,  camphor, 


HYSTERIA. 

asafoetida,  &c.,  in  an  hysterical  paroxysm,  because  attention  had 
not  been  paid  to  the  circulatory  system  ?  Yet  after  the  loss  of  a 
few  ounces  of  blood,  they  have  often  been  rendered  immediately 
efficient.  The  connexion  between  the  nervous  and  arterial  sys- 
tems is  more  intimate  than  is  generally  admitted ;  and,  to  be  suc- 
cessful in  prescribing  for  derangements  of  the  former,  we  must 
have  a  scrupulous  regard  to  the  state  of  the  latter. 

Indeed,  a  case  can  scarcely  occur,  in  which  it  would  be  safe 
to  disregard  the  state  of  the  circulation  altogether  in  the  treat- 
ment of  nervous  affections;  for  though  it  may  not  be  labouring 
under  any  undue  excitement  at  the  moment,  yet  it  may  be  very 
easily  roused  into  morbid  action  by  the  undue  application  of  sti- 
muli. For  the  force  of  stimuli  must  be  regulated  by  the  suscep- 
tibility of  the  vascular  system  to  action,  if  success  is  to  follow 
their  exhibition — thus,  ten  or  fifteen  drops  of  laudanum,  under 
certain  conditions  of  the  system,  may  be  more  successful  than 
three  times  this  quantity  under  another  state  of  arterial  action  ; 
and  the  same  observation  will  apply  to  many  other  remedies  em- 
ployed in  nervous  affections ;  for  the  success  of  remedies  must 
depend  upon  their  being  administered  in  due  force,  to  the  exist- 
ing condition  of  the  system. 

It  is  every  way  certain  that  plethora  will  often  give  rise  to  a 
train  of  nervous  symptoms,  or  to  hysteria:  now  these  cases,  if 
treated  from  the  commencement  by  stimulants,  or  antispasmo- 
dics,  will  surely  be  aggravated ;  while  the  abstraction  of  a  few 
ounces  of  blood  will  almost  instantly  tranquillize  the  system,  and 
render  farther  applications  perhaps  unnecessary.  It  will  be  well 
to  illustrate  this  by  a  case. 

Mrs.  B.,  aged  thirty  years,  three  months  pregnant  with  her 
fifth  child,  complained  of  great  palpitation  of  the  heart ;  lowness 
of  spirits ;  head  felt  as  if  girded  by  a  cord ;  easily  provoked  to 
tears,  hands  and  feet  cold,  with  very  frequent  discharges  of 
urine;  loss  of  appetite;  nausea,  and  occasionally  vomiting:  pulse 
full  and  tense.  She  was  ordered  to  lose  ten  ounces  of  blood ; 
and  to  take  a  dose  of  rhubarb  and  magnesia.  She  was  imme- 
diately bled ;  and  so  effectual  was  the  relief  from  it  that  she  did 
not  think  it  necessary  to  take  the  purgative  medicine. 

Had  this  case  been  treated  with  stimulants,  or  antispasmodics, 
there  is  no  doubt  that  every  symptom  would  have  been  aggra- 
vated ;  at  all  events  they  would  not  have  been  relieved. 

I  do  not,  however,  mean  to  insinuate  that  every  case  attended 
with  the  above  enumerated  symptoms  would  be  relieved  by  the 
loss  of  blood.  I  wish  merely  to  inculcate  the  necessity  of  ascer- 
taining the  state  of  the  arterial  system,  before  a  prescription  is 
made  for  what  is  familiarly  termed  nervous  symptoms ;  and  if 
this  be  found  too  active,  it  must  be  reduced  before  stimulants 
and  antispasmodics  are  administered.  It  is  also  important  to  be 


486  HYSTERIA. 

mindful  of  the  state  of  the  circulation  during  the  use  of  active 
remedies ;  for  it  may  happen,  nay,  it  very  often  does,  that  during 
the  exhibition  of  them  the  pulse  becomes  too  much  excited,  and 
all  the  nervous  symptoms  become  aggravated. 

To  relieve  this  condition  it  is  but  too  common  a  practice  to 
increase  the  doses  of  the  stimulants  in  use ;  which,  instead  of  pro- 
ducing the  desired  effect,  but  augment  the  difficulty.  In  such 
cases  the  loss  of  a  few  ounces  of  blood;  a  brisk  purge;  a  sus- 
pension of  the  remedies ;  or  even,  sometimes,  a  reduction  of  the 
quantity,  will  have  the  happiest  result. 

In  the  treatment,  therefore,  of  hysterical  or  nervous  affections, 
too  much  latitude  is  commonly  given  to  patients ;  than  which 
nothing  can  be  more  erroneous.  It  is  generally  supposed  by 
them,  that  if  a  small  dose  will  do  good,  a  larger  will  do  better ; 
or,  at  all  events,  a  quick  repetition  of  it  is  every  way  necessary: 
they  accordingly  act  upon  this  principle;  and,  but  too  often,  to 
their  injury.  For,  however  proper  these  remedies  may  be,  they 
can  only  be  so  certainly  in  appropriate  doses;  if  these  be  ex- 
ceeded, either  no  relief  will  be  obtained,  or  the  complaint  will  be 
increased.  It  should,  therefore,  ever  be  a  rule  in  practice,  even 
in  nervous  diseases,  to  suit  the  force  of  the  remedy  to  the  state 
of  the  system,  as  far  as  this  may  be  practicable. 

It  will  be  acknowledged,  almost  upon  all  hands,  that  this  im- 
portant point  has  been  too  much  neglected ;  hence  the  but  too 
frequent  failure  of  remedies  in  the  diseases  in  question. 

Dr.  Whytt,1  when  about  to  lay  down  the  cure  for  "  nervous 
disorders,"  makes  use  of  the  following  judicious  language:  "It 
will  be  proper  to  observe,  that,  as  it  is  generally  in  the  power  of 
medicine  to  relieve,  it  is  frequently  beyond  the  power  of  art  to 
eradicate  the  disorders  we  now  treat  of;  and,  therefore,  it  may 
be  often  of  use  to  intimate  this  to  our  patients,  especially  to  such 
as  have  fortitude  enough  to  bear  those  evils  which  can  neither 
be  wholly  prevented  nor  fully  cured.  It  is  farther  necessary  to 
acquaint  every  patient,  that  without  a  long  perseverance  in  a 
course  of  medicines,  diet,  and  exercise,  no  great  or  lasting  bene- 
fit can  be  expected."  To  this  purpose  is  the  following  passage  of 
Montanus,  which  equally  deserves  the  attention  of  such  patients 
as  are  affected  with  nervous  ailments,  and  of  the  physicians  who 
undertake  their  cure.  "  In  curatione  hujus  morbi,  (sciz.  hypo- 
chondriaci,)  non  licet  praefinire  tempus  mensis  unius  aut  anni, 
sicut  in  aliis  contingat ;  sed  oportet  in  toto  vitse  suae  tempore 
curationi  operam  dare  interdum  curationi,  interdum  prseserva- 
tioni,  attendo." 

Hysteria  is  seldom  cured  so  effectually  as  that  the  patient 
shall  have  no  farther  returns  of  it,  should  an  exciting  cause  be 

*  Works,  p.  632. 


HYSTERIA.  487 

applied ;  yet  we  know  from  ample  experience  that  it  can  be  much 
mitigated  by  proper  moral  and  medical  discipline.  Too  much, 
we  believe,  has  been  taken  for  granted  by  medical  men  upon  the 
subject  of  this  disease;  for  it  seems  to  be  admitted,  and  this  with 
by  far  too  much  facility,  that  little  or  nothing  can  be  done  for 
hysterical  patients  beyond  the  temporary  relief  of  the  paroxysm. 
This  indifference  upon  the  subject  of  hysteria  has  prevented  suf- 
ficient inquiry  into  the  nature  and  causes  of  this  formidable  dis- 
ease; and  the  modes  of  treating  it  remain  very  much  the  same 
as  they  did  in  the  time  of  Sydenham. 

The  difficulties  experienced  in  the  treatment  of  this  complaint 
appear  to  us  to  be  rather  accidental  than  essential ;  and  this  be- 
lief is  founded  on  the  following  well  established  facts :  namely, 
first,  we  now  and  then  see  females,  who  have  been  subject  to  it 
at  one  period  of  their  lives,  exempt  from  it  at  another;  secondly, 
care  taken  to  avoid  the  exciting  cause  will,  for  many  years  to- 
gether, prevent  the  return  of  the  paroxysms.  Now,  it  would 
seem,  that  if  this  affection  can  be  removed,  or  even  considerably 
relieved,  either  by  means  which  we  do  not  exactly  understand, 
by  the  proper  exercise  of  moral  restraints,  or  by  the  removal  of 
certain  exciting  causes,  we  might  be  encouraged  to  hope  that 
the  proper  application  of  means,  when  the  pathology  of  the  dis- 
ease shall  be  better  understood,  might  be  successful.  But  if  hys- 
teria be  always  looked  upon  as  one  of  the  opprobria  medicorum, 
it  cannot  be  expected  we  shall  ever  be  much  better  acquainted 
with  its  nature  or  method  of  cure. 

It  is  ever  proper  that  the  medical  man  should  hold  the  opinion 
that  every  disease  is  susceptible  of  cure ;  for  this  belief  will  sti- 
mulate him  to  investigations  which  may  result  in  success ;  but  if 
he  permit  himself  to  think  that  certain  diseases  are  without  re- 
medy, exertion  will  be  paralyzed,  and  inquiry  will  cease.  The 
lues  venerea,  intermittents,  and  doubtless  many  other  diseases, 
were,  at  different  periods  of  the  world,  thought  to  be  incurable, 
however  easy  of  subjection  they  may  be  at  the  present  day. 

The  following  cases  will  show  that  this  formidable  complaint 
may  be  subdued  by  moral  and  physical  causes. 

Case  First. 

•   •    ft  '  '('  :\ji<' tr  v«j  rfHi'.!j-i  • ' .:    •..  -t.  :   ..;   •        ;  .tJSf 

Mrs. ,  of  sanguine  temperament,  married  early  in  life,  and 

became  the  mother  of  a  large  healthy  family.  She  herself  on- 
joyed  uninterrupted  good  health,  until  her  previous  habits  were 
broken  up  by  her  husband  becoming  very  rich  from  successful 
speculations.  She  was  now  under  no  necessity  of  working  for 
the  sake  of  her  family;  every  thing  that  money  could  purchase 
was  at  her  command.  She  occupied  a  large  house ;  employed 


488  HYSTERIA. 

a  number  of  servants;  and  performed  in  a  carriage  that  which 
was  before  done  on  foot.  She  fed  high,  and  became  really  luxu- 
rious. But  this  change  of  fortune  had  penalties;  and  they  were 
severe  ones;  she  soon  became  very  corpulent,  listless,  and  ex- 
tremely nervous.  She  was  frequently  assailed  by  hysterical  pa- 
roxysms of  great  severity,  and  of  long  duration.  She  became 
peevish  to  all  around  her,  and  extremely  jealous  of  her  husband. 
Every  action  of  his  life  was  misinterpreted,  though  he  was  one 
of  the  best  and  most  moral  men  in  the  world ;  and  frequently  did 
her  "fits"  arise  from  this  overweening  anxiety  of  her  husband's 
supposed  bad  conduct. 

She  continued  in  this  fretful  and  anxious  state  for  a  number  of 
years;  and  became  so  debilitated  at  last,  that  she  could  not  leave 
her  chamber  for  months  together ;  and  it  was  thought  by  her  me- 
dical attendants  she  must  soon  sink  under  her  malady.  But  at 
this  time  the  scene  of  prosperity  was,  by  one  of  those  changes 
common  to  mercantile  life,  suddenly  changed  for  that  of  compara- 
tive poverty.  Her  husband  gave  all  his  effects  to  his  creditors ; 
and  after  satisfying  them,  little  remained.  The  effect  of  this  re- 
verse upon  the  disease  of  the  lady  was  no  less  sudden  than  salu- 
tary ;  and  that  which  it  was  thought  would  cause  her  death  proved 
her  cure.  For  from  this  moment  she  discharged  her  servants ; 
gave  up  her  coach;  dismissed  her  physicians;  reinstated  herself 
in  her  former  occupations,  and  re-assumed  her  former  habits,  as 
far  as  her  state  of  health  would  at  the  moment  permit. 

In  consequence  of  this  change  of  circumstances,  her  moral 
energies  were  roused,  and  she  quickly  showed  to  the  world  that 
her  temporary  elevation  had  not  unfitted  her  for  a  profitable  re- 
turn to  her  former  habits:  and  by  exercising  them,  she  soon  re- 
gained that  health  which  had  been  so  completely  sacrificed  at 
the  shrine  of  wealth;  for  after  the  first  shock  was  over,  she 
never  had  an  hysterical  paroxysm. 

!irif,")iii  '••'  r-J  fiiu.r;  ).';  <'  fU  lo  fcl>!.'hv.:£  Jiiorjfii!.'  !;:  ,>n<f 

Case  Second. 
iTi&ttl8$9  •;      mftfiGi  t     ;  ;_>',.;  Y/  --tic.  i.i~tr  b  >r:av  jintvoii.  4  •. -.-i'i 

A  lady,  born  in  a  northern  climate  of  Europe,  went  with  her 
husband,  after  being  the  mother  of  three  children,  to  one  of  the 
West  India  Islands.  Here  her  health  soon  suffered  from  the  cli- 
mate; she  had  frequent  abortions,  by  which  she  was  much  re- 
duced by  the  attending  hemorrhages.  She  became  very  hyste- 
rical; and  paroxysms  would  be  produced  by  the  slightest  causes. 
Her  physicians  advised  she  should  be  taken  to  a  northern  cli- 
mate ;  and  she  arrived  in  Philadelphia  in  a  most  reduced  state. 

She  would  not  unfrequently  have  three  or  four  "fits"  in  a 
week,  for  some  time  after  her  arrival.  She  had  aborted  a  few 
weeks  before,  and  was  still  labouring  under  a  coloured  discharge 


HYSTERIA.  489 

from  the  vagina.  The  usual  tonics  were  administered  with  ad- 
vantage, and  she  soon  acquired  an  addition  of  strength ;  the  ute- 
rine discharge  was  arrested,  and  the  hysterical  paroxysms  were 
diminished  both  in  force  and  frequency.  The  first  object  in  view 
was  the  renewal  of  strength ;  and  the  second  to  prevent  impreg- 
nation, while  she  continued  so  feeble,  as  had  been  the  case  too 
often  before. 

The  husband  had  business  in  Europe ;  and  we  begged  him  to 
hasten  his  departure,  or  exercise  forbearance ;  for  which  we 
candidly  gave  our  reasons.  He  went ;  and  his  wife  improved 
daily  under  the  use  of  the  cold  bath,  air,  exercise,  and  a  strict- 
ly regulated  diet,  both  as  to  quantity  and  quality.  Her  strength 
improved  daily ;  her  appetite  increased ;  her  digestion  was  well 
performed;  and  her  alvine  excretions  regular.  She  would  now 
be  weeks  together  free  from  hysterical  attacks ;  and  by  pursuing 
this  plan  regularly  for  fourteen  months  she  lost  them  altogether; 
for  she  has  had  no  return  up  to  this  moment,  a  period  of  several 
years. 

Her  husband  returned  after  an  absence  of  eighteen  months, 
and  she  has  since  had  two  live  born  children.  In  consequence 
of  her  improved  health  in  this  climate,  she  has  been  permitted 
to  remain.  These  cases  show  that  established  hysterical  parox- 
ysms with  their  attendants,  were  subdued  by  changes  of  a  moral 
and  physical  kind ;  and  that  they  hold  out  encouragement  to  treat 
this  affection  as  one  capable  of  cure.  But  we  must  repeat,  that 
success  can  only  be  expected,  where  the  patient  will  most  sedu- 
lously co-operate  with  the  exertions  of  the  physician. 

The  treatment  of  hysteria  will  embrace  what  is  proper  to  be 
done  during  the  paroxysms,  and  what  may  be  necessary  in  the 
intervals. 


1.   Of  the  Paroxysms. 

The  management  of  the  paroxysms  is  oftentimes  one  of  great 
difficulty,  from  the  excessive  force  with  which  it  agitates  the 
body.  The  whole  muscular  system  is  violently  exercised,  and 
this  to  a  degree  that  almost  exceeds  belief,  even  in  women  who 
are  at  other  times  very  feeble.  The  circulatory  system  is  almost 
always  excited,  and  a  strong  determination  to  the  head  is  declared 
by  the  suffused  cheeks,  the  swollen  face,  the  blood-shotten,  pro- 
truding eye,  the  distended  jugulars,  the  throbbing  carotids,  and 
the  never-failing  but  temporary  mental  alienation. 

Notwithstanding  these  strong  evidences  of  the  determination 
of  blood  to  the  head,  many  practitioners  doubt  the  propriety  of 
blood-letting  in  hysteria,  because  they  declare  it  to  be  a  "nervous 
disease,  and  that  drawing  blood  is  always  injurious  in  such  cases." 


490  PYSTERIA. 

Such  sweeping  declarations  must  necessarily  be  very  often  wrong, 
and  tend  too  decidedly  to  retard  improvement  in  the  practice  of 
medicine,  since  they  are  almost  always  based  upon  narrow  or 
imperfect  views  of  the  animal  system.  They  should,  therefore, 
always  be  received  with  hesitation,  and  acted  upon  with  caution. 
We  have  remarked  above,  that  this  prejudice  against  blood-letting, 
(for  it  deserves  no  better  name,)  has  retarded  the  cure  of  many 
of  the  affections  termed  nervous :  this  apprehension  should  there- 
fore be  laid  aside,  and  more  reliance  placed  upon  the  state  of  the 
circulating  system.  The  pulse  should  constantly  be  the  guide 
upon  all  such  occasions,  and  if  this  be  properly  studied  and  well 
understood,  it  will  always  direct  us  safely  in  the  employment  or 
the  withholding  of  the  lancet. 

The  condition  of  the  system  during  an  hysterical  paroxysm  is 
almost  always  one  of  high  excitement;  nor  will  this  surprise  us, 
when  we  reflect  upon  the  period  of  life,  the  kind  of  tempera- 
ment, the  nature  of  the  exciting  causes,  and  the  importance  of 
the  parts  principally  concerned  in  the  disease.  Besides  these 
general  reasons,  which  are  of  no  small  force,  we  shall  find  one 
still  more  powerful  in  the  pulse  itself.  It  will  almost  always  be 
found  rapid,  full,  and  tense,  and  most  unequivocally  declaring  a 
necessity  for  abstracting  blood,  and  sometimes  even  to  a  large 
amount. 

\Ye,  therefore,  with  very  few  exceptions,  direct  the  loss  of 
blood  to  an  extent  that  shall  decidedly  diminish  the  force  of  the 
pulse,  before  we  employ  any  other  remedy.  Bleeding  does  not 
often  put  an  end  to  the  fit  immediately,  nor  is  this  expected  of 
it;  it,  however,  lays  the  foundation  for  other  remedies  to  be  suc- 
cessful, which  would  not  be  the  case  without  it.  Nor  is  this  all : 
it  always,  we  believe,  shortens  the  "fit;"  and  certainly  very 
often  prevents  its  becoming  protracted,  or  ending  in  mischievous 
engorgements. 

After  bleeding  we  can  employ  remedies  agreeably  to  the  pre- 
senting indications  with  much  more  certainty  and  safety.  We 
should  inquire  into  the  nature  of  the  exciting  cause,  and  be  much 
directed  by  its  nature.  It  may  be  owing  to  a  passion,  or  an  emo- 
tion of  the  mind;  if  this  be  so,  sedatives  and  antispasmodics 
should  be  given.  These  may  be  administered  by  the  mouth  or 
by  the  rectum,  as  may  be  most  expedient.  If  the  patient  can 
be  made  to  swallow,  and  it  rarely  happens  that  she  cannot,  if 
advantage  be  taken  of  an  interval,  laudanum,  in  a  full  dose, 
should  be  given,  and  may  be  repeated  in  an  hour,  half  an  hour, 
or  more  seldom,  as  necessity  may  require.  It  may  be  combined 
with  a  solution  or  the  tincture  of  asafoetida,  in  drachm  doses. 
Cold  water  may  be  freely  dashed  upon  the  face,  or  even  a  stream 
of  it  turned  upon  it. 

Dr.  Whytt,  (Works,  p.  693,)  after  enumerating  a  number  of 


HYSTERIA.  491 

remedies  thought  to  be  useful  in  the  paroxysm,  winds  up  with 
the  following  declaration :  "But  there  is  no  remedy  which  I  have 
found  so  effectual  in  removing  hysterical  faintings,  with  convul- 
sions, as  the  warm  pediluvium;  for  after  many  other  things  had 
been  tried  to  no  purpose,  I  have  seen  the  patients  restored  to  their 
senses  almost  instantly,  by  putting  their  feet  and  legs  in  water  a 
little  more  than  blood  warm.  And  it  was  remarkable,  that  upon 
the  discontinuing  the  pediluvium  too  soon,  the  faintings  and 
catchings  often  returned  in  a  less  degree,  and  the  pulse  became 
smaller  and  irregular.  In  a  few  cases,  where  the  patients  were 
plethoric,  and  the  convulsions  very  strong,  the  pediluvium  has 
failed." 

Of  this  remedy  in  the  convulsive  stage  of  hysteria  we  can  say 
nothing  from  our  own  experience,  but  the  authority  of  Dr. Whytt 
is  sufficient  to  produce  reliance  on  it.  The  only  objection  we 
perceive  in  the  use  of  the  pediluvium  is  the  difficulty  of  its  ap- 
plication at  the  moment  the  patient  is  convulsive — flannels,  or 
a  blanket  wrung  out  of  hot  water  and  applied  to  the  legs  might 
answer.  His  last  observation  on  the  cause  of  the  failure  of  this 
remedy,  is  worthy  of  remark,  namely,  but  "where  the  patients 
were  plethoric,  it  failed :  "  this  clearly  points  out  the  necessity  of 
that  strict  attention  we  have  recommended  to  the  state  of  the 
pulse. 

It  is  recommended  by  almost  all  writers,  and  certainly  prac- 
tised by  all  by-standers,  to  hold  volatiles,  and  other  stimulating 
things  or  substances  to  the  nostrils  during  the  "fit."1  This  is 
certainly  a  very  doubtful  practice  where  the  system  is  much 
excited,  and  the  convulsions  violent.  It  is  applying  a  powerful 
stimulus  to  a  very  sensitive  part,  a  part  that  very  powerfully 
sympathizes  with  the  brain,  and  most  probably  the  brain  with 
it,  at  a  time  when  the  abstraction  of  stimuli  is  highly  desirable. 
This  practice  most  probably  arose  from  the  success  of  such  sub- 
stances in  syncope;  but  between  syncope  and  an  hysterical  con- 
vulsion there  is  not  the  slightest  analogy :  in  one  instance,  the 
muscular,  the  arterial,  and  nervous  systems  are  violently  excited; 
in  the  other,  they  are,  for  the  time  being,  paralyzed. 

At  a  very  early  period  of  our  medical  practice,  the  propriety 
of  this  plan  was  doubted :  this  arose  from  seeing  a  person  in  an 
hysterical  paroxysm  constantly  thrown  into  a  convulsion  by  the 

1  Dr.  Whytt  recommends  the  employment  of  such  substances  during  the  fit, 
and  says,  "These  medicines,  by  the  strong  and  sudden  impression  they  make  on 
the  very  sensible  nerves  of  the  nose,  not  only  tend  to  excite  the  several  organs 
into  action,  but  to  lessen  and  destroy  the  disagreeable  sensation  in  that  part  of 
the  body  which  brought  on  the  fit."  Works,  p.  692,  693.  But  a  little  while 
after  we  find  him  at  variance  with  himself,  by  saying,  that  "  warm  water  is  not 
only  the  speediest,  but  the  safest  cure  for  hysteric  faintings;  while  strong  vola- 
tiles, held  to  the  nose,  are  apt  to  throw  some  delicate  women  into  more  violent 
convulsions,"  p.  65)3. 


492  HYSTERIA. 

i 

application  of  the  volatile  spirit  of  hartshorn  to  the  nose,  while 
she  lay  in  a  state  of  comparative  tranquillity  after  an  exhausting 
"fit."  In  this  instance,  the  volatile  was  no  sooner  applied  than 
the  convulsion  was  renewed  :  the  practice  was  peremptorily  for- 
bidden, and  the  patient  soon  "  came  out  of  the  fit."  Since  that 
period  we  have  never  permitted  the  employment  of  volatiles  in 
•an  hysterical  paroxysm ;  and  so  far  we  have  been  perfectly  satis- 
fied with  the  plan. 

Should  the  patient  be  unable  to  swallow,  we  direct  the  laudanum 
and  asafoetida  to  be  given  by  "injection,"  having  the  bowels 
previously  emptied  by  one  consisting  of  a  pint  of  warm  water 
and  a  large  table-spoonful  of  common  salt.  The  anodyne  and 
antispasmodic  enema  is  to  consist  of  two  wine-glassfuls  of  luke- 
warm water,  a  full  drachm  of  laudanum,  and  as  much  tincture 
of  asafoetida,  or  if  the  watery  solution  of  the  asafoetida  be  at 
hand,  it  may  be  used  instead  of  the  plain  water.  This  injection 
may  be  repeated  pro  re  nata,  every  hour  or  two,  as  the  exigency 
may  demand. 

It  is  sometimes  difficult  to  administer  an  enema  during  the 
"fit,"  for  we  have  remarked  that  the  struggle  during  this  time 
is  severe  and  irresistible ;  besides  there  is  another  difficulty  to  this 
process,  which  arises  from  the  contracted  condition  of  the  sphinc- 
ter ani,  but  this  can  always  be  overcome  by  perseverance  and  ad- 
dress, so  far  as  we  have  yet  witnessed  ;  it  should  not  therefore  be 
abandoned  too  soon,  if  the  patient  cannot  swallow.  See  p.  480. 

Hysterical  paroxysms  sometimes  depend  upon  something  taken 
into  the  stomach,  as  too  large  a  quantity  of  indigestible  food,  &c. 
When  this  is  ascertained  to  be  the  case,  an  emetic  should  imme- 
diately follow  the  bleeding,  if  this  has  been  judged  necessary. 
Sydenham  recommended  this  practice  long  since,  and  the  expe- 
rience of  almost  every  body  since  his  time  has  confirmed  its  effi- 
cacy. Sometimes  severe  vomiting  attends  the  paroxysm  :  when 
this  is  the  case,  it  should  be  encouraged  by  warm  water  when 
practicable,  until  it  appears  that  the  stomach  is  cleansed.  This 
case,  agreeably  to  Sydenham,  requires  a  larger  dose  of  laudanum 
than  where  no  vomiting  attends. 

If  there  be  much  costiveness,  besides  the  injection  of  salt  and 
water,  a  strong  infusion  of  senna  should  be  given,  in  such  doses 
as  the  patient  can  be  made  to  swallow,  and  at  such  intervals  as 
shall  be  judged  necessary,  until  it  operate  freely.1 

It  sometimes  becomes  necessary  to  apply  blisters  to  the  calves 
of  the  legs,  or  sinapisms  to  the  feet ;  these  are,  however,  only 

1  The  senna  seems  to  be  peculiarly  appropriate  in  this  case,  for  its  griping  has 
sometimes  advantages  not  to  be  derived  from  other  cathartics.  This  is  especially 
the  case  when  the  convulsions  are  frequent,  and  when  attended  by  strong  evi- 
dences of  determination  to  the  head. 


HYSTEKIA.  493 

useful  where  there  js  a  disposition  to  coma  after  the  convulsions 
have  ceased.1 

The  paroxysms  are  of  longer  or  shorter  duration ;  and  it  is  not 
unusual  to  find  the  patient,  after  a  severe  "fit,"  rouse  up,  as  if 
little  or  nothing  had  happened:  when  this  is  the  case,  the  disease 
is  habitual,  for  the  most  part,  and  not  of  much  force.  At  other 
times  they  appear  to  fall  into  a  profound  sleep  after  each  struggle; 
and  if  now  let  alone,  they  would  awake  perfectly  well.  But  if 
anxiety  has  put  in  practice  the  application  of  volatile  substances 
to  the  nostrils,  it  may  do  mischief,  by  renewing  the  convulsions, 
as  stated  above.  Therefore,  when  this  condition  occurs,  it  should 
not  be  interrupted  by  improper  officiousness;  for  this  state  of 
tranquillity  is  the  best  possible  thing  for  the  patient. 

When  the  patient  has  warning  of  an  approaching  paroxysm, 
it  may  frequently  be  interrupted  by  a  timely  dose  of  laudanum, 
asafoetida,  or  Hoffman's  anodyne  liquor;  or  what  we  have  fre- 
quently found  to  answer  well  in  such  cases,  is  equal  parts  of  the 
volatile  tincture  of  valerian  and  castor,  in  drachm  doses,  mixed 
in  sweetened  water,  provided  much  headache  does  not  attend ; 
for  if  this  be  the  case,  the  paroxysm  can  only  be  put  aside,  or 
moderated,  by  a  bleeding,  followed  by  a  brisk  cathartic.  A  pa- 
tient of  ours  rarely  fails  to  prevent  a  "fit"  by  this  plan.2 

In  no  disease,  perhaps,  has  so  many  remedies  been  employed, 
as  in  hysteria ;  at  least,  during  the  paroxysm :  almost  all  the 
strong-smelling  plants,  oils,  gums,  and  chemical  products,  have 
been  employed,  and  lauded,  condemned,  and  laid  aside,  in  their 
turn.  In  this,  perhaps,  we  have  lost  nothing ;  for  had  they  pos- 
sessed any  remarkable  advantages  over  the  asafoetida,  (almost 
the  only  one  now  employed,)  they  would  unquestionably  have 
been  retained  as  certainly  as  it  has  been.  Indeed,  we  are  dis- 
posed to  believe  that  they  would  never  have  been  introduced 
among  the  anti-hysterical  medicines,  but  from  their  strong  smell 
exciting  an  analogy  to  the  asafoetida,  which  has  ever  merited 
some  confidence  in  hysteria. 

Dr.  Hamilton  believing  the  disease  to  be  seated  in  the  stomach 

1  Mr.  Tate,  in  conformity  with  hia  pathological  views,  (see  note  at  page  479,) 
declares  he  has  seen  the  most  decided  beneficial  effects  from  the  use  of  the  tartar 
emetic  ointment,  rubbed  upon  the  dorsal  vertebrae  until  it  produces  vesication. 

*  Patients  afflicted  with  hysteria  frequently  experience  sensations  which  warn 
them  that  a  paroxysm  is  at  hand,  and  waiting  only  for  an  exciting  cause  to  call  it 
into  play  —  under  such  impressions  relief  or  prevention  is  sought,  in  various 
ways,  by  different  individuals.  Some  seek  cheerful  company  and  amusements, 
others  active  occupation;  some  let  blood,  others  stimulate,  &c.;  and  all,  as  is  often 
in  their  power,  after  they  have  become  well  acquainted  with  their  malady,  shun 
well-known  exciting  causes.  A  lady  with  whom  we  are  well  acquainted,  and 
who  is  well  versed  in  the  premonitory  symptoms  of  hysteria,  will  not,  while 
labouring  under  these  sensations,  open  a  letter  of  any  kind  addressed  to  her.  They 
are  thrown  aside,  until  she  feels  she  may  encounter  with  impunity  any  information 
they  may  contain. 


494  HYSTERIA. 

• 

and  bowels,  gives,  with  his  usual  freedom,  purgative  medicines ; 
the  good  effects  of  which,  on  this  presumption,  he  illustrates  by 
several  cases.  But  these  cases  prove  nothing  in  favour  of  his 
pathology ;  since  purging  is  but  a  mode  of  depletion ;  and  one 
which  is  as  familiarly  employed  for  affections  of  the  brain  as  for 
those  of  the  abdominal  viscera.  In  young,  robust  and  healthy 
women,  and  especially  those  in  whom  the  disease  has  not  yet 
assumed  a  chronic  form,  we  have  always  found  purging  highly 
useful,  and  never  fail  to  employ  some  of  the  most  active  of  the 
class  for  this  purpose ;  such  as  senna,  calomel  and  jalap,  various 
combinations  of  gamboge,  scammony,  &c. 

Hysterical  paroxysms  may  be  excited  by  a  variety  of  causes, 
and  especially  those  which  act  directly  upon  the  mind ;  and  when 
these  cannot  absolutely  be  removed,  the  consequences  may  fre- 
quently be  diminished  by  the  repeated  use  of  opium.  The  cases 
in  which  laughing,  crying,  a  sense  of  suffocation,  palpitation  of 
the  heart,  and  mental  alienation,  without  convulsions,  occur,  can 
almost  always  be  restrained  by  the  liberal  use  of  this  drug ;  pro- 
vided no  plethora  exist,  or  after  it  may  have  been  removed  by  a 
bleeding. 

The  following  case  will  serve  as  one  of  many,  as  an  illustra- 
tion. Mrs. ,  hearing  suddenly  of  the  death  of  a  brother,  to 

whom  she  was  much  attached,  and  whom  she  for  some  days  had 
hourly  expected  to  see,  was  instantly  seized  with  such  an  aliena- 
tion of  mind,  as 'to  pervert  the  kind  offices  of  her  best  friends  into 
attempts  to  injure  her.  She  talked  incessantly  of  her  brother; 
cried  and  laughed  by  turns  ;  complained  she  was  strangling,  and 
required  air,  &c.  We  persuaded  her  to  take  a  little  coffee,  in 
which  was  mixed  thirty-five  drops  of  "black  drop:"  this  was  re- 
peated once  an  hour  for  four  doses.  She  now  became  calm ;  was 
unconscious  of  any  thing  that  had  happened,  and  fell  into  a  sound 
sleep,  which  lasted  twelve  hours.  She  awoke  from  this  state 
perfectly  restored. 

The  best  form  for  exhibiting  opium  is  in  that  form  of  lauda- 
num called  the  "black  drop,"  or  the  tinct.  thebaic,  acetat.1  In 
this  form  it  rarely  leaves  behind  the  unpleasant  feelings  the  com- 
mon laudanum  does.  It  is  of  about  double  the  strength  of  the 
common  laudanum. 

But  should  this  preparation  not  be  at  hand,  the  common  lau- 
danum should  be  mixed  with  two  tea-spoonsful  of  sweetened  vi- 
negar, which  answers  nearly  the  same  purpose.  In  the  use  of 

1  We  may  give  the  new  preparation  of  opium,  called  the  "  denarcotized  lauda- 
num," with  still  greater  impunity,  as  it  more  rarely  offends  than  the  black  drop. 
If  this  preparation  be  made  choice  of,  it  should  be  given  in  as  large  doses  as  if 
the  common  laudanum  were  employed.  Or  with  equal,  if  not  greater  advantage, 
the  sulphate  of  morphia — a  grain  of  which  is  about  equal  to  one  hundred  and 
twenty  drops  of  laudanum. 


HYSTEKIA.  495 

this  medicine  strict  attention  should  be  paid  to  the  peculiarities 
of  the  system  as  regards  opium.  There  are  many  who  cannot 
use  the  smallest  quantity  when  given  in  one  form,  yet  can  bear 
full  doses  when  exhibited  in  certain  other  forms ;  for  instance,  we 
know  several  who  cannot  take  the  common  laudanum  in  any\ 
quantity,  yet  can  use  the  black  drop  with  freedom  and  without 
the  slightest  inconvenience ;  others  can  take  the  laudanum,  when 
mixed  with  a  few  grains  of  the  carbonate  of  potash,  or  of  soda : 
others  can  only  use  the  solid  opium ;  and  some  few  we  have  met 
with,  who  cannot  use  the  black  drop,  yet  will  bear  the  common 
laudanum  well,  &c.  &c.  Attention  should  always  be  paid  to 
such  peculiarities,  when  they  exist;  for,  on  them,  very  often, 
much  will  depend.  Dr.  Whytt  gives  a  remarkable  instance  of 
this  kind  of  idiosyncrasy.  A  middle-aged  lady  whom  four  or 
five  drops  of  laudanum,  taken  by  the  mouth,  affected  with  a 
violent  pain  and  cramp  in  her  stomach ;  and  sixteen  drops  taken 
in  a  clyster,  though  they  did  not  occasion  these  complaints, 
made  her  delirious  for  twelve  hours."  Works,  p.  645.  We 
have  seen  several  instances  in  which  the  "black-drop"  invariably 
gave  colic. 

This  peculiarity,  as  regards  opium,  is  oftentimes  very  unfortu- 
nate, as  it  deprives  the  patient  of  the  use  of  the  only  remedy  ca- 
pable of  relieving  the  existing  symptoms.  We  have  two  patients, 
much  subject  to  cough ;  neither  of  whom  can  bear  opium  in  any 
form  we  have  been  able  to  invent.  One  of  them  dare  not  use  it 
even  externally.  In  constitutions  thus  peculiarly  constituted  it 
might  be  well  to  follow  the  suggestions  of  Whytt  upon  this  sub- 
ject. He  observes,  that  the  lady,  (whose  case  has  just  been  re- 
lated,) "having  afterwards  begun  with  one  drop  of  laudanum, 
gradually  raised  it  to  twenty-five  drops;  nay,  she  has  sometimes 
taken  that  quantity  thrice  a  day,  without  feeling  any  of  its  former 
bad  effects;"  which  would  seem  to  declare,  that  this  unfortunate 
peculiarity  might  be  overcome  by  beginning  with  very  small 
doses,  and  gradually,  and  almost  insensibly,  increasing  them. 

When  the  hysterical  paroxysm  precedes  the  eruption  of  the 
menses,  it  is  generally  best  relieved  by  camphor,  or  camphor  and 
opium  conjoined:  this  may  be  given  in  julep,  or  in  powder,  as 
may  be  most  convenient.  The  following  formula  we  have  found 
to  answer  very  well — 

R. 


VTUIII     <    .mij'll. 

Sp.  \in.  rect. 
Pulv.  g.  Arab. 
Tinct.  thebaic. 
Sacch.  alb. 
Aq.  Font. 

icetat. 

q.  s.  f.  pulv.  adde 

gut.  lx. 
$"')• 

IVJ.-M 

Of  this,  a  table-spoonful  may  be  taken  every  hour  or  two,  as 
the  case  may  be  more  or  less  urgent. 

In  cases  where  it  is  known  that  opium  in  almost  any  shape 


490  HYSTERIA. 

or  quantity  will  disagree,  it  may  be  omitted,  and  tlie  simple  cam- 
phorated julep  used  in  its  stead.  But  it  should  be  well  ascer- 
tained that  the  system  does  not  require  lowering  by  blood-letting 
before  even  the  camphor  is  given:  for,  should  the  pulse  be  too 
active,  much  less  advantage  will  be  obtained  from  it ;  and  it  will 
render  the  exhibition  of  opium  altogether  improper. 

Local  applications  are  sometimes  of  advantage  in  such  cases, 
especially  if  the  feet  be  cold — pediluvium,  as  warm  as  can  be  well 
borne,  will  be  found  highly  serviceable,  according  to  Whytt;  and 
we  know,  that  sinapisms  to  the  feet,  and  warm  dry  applications 
to  the  region  of  the  uterus,  are  of  much  benefit. 

It  is  almost  the  universal  practice  of  the  attendants  on  a  person 
in  the  "hysterics,"  to  oppose  by  violence,  as  far  as  their  strength 
will  enable  them,  every  motion  of  the  patient's  body.  They  sup- 
pose the  hands  must  be  unclenched,  at  all  events  ;  and  very  often, 
in  the  performance  of  this  work  of  supererogation,  much  injury 
is  sustained  by  the  muscles  that  flex  the  hand  and  fore-arm.  This 
violence  should  be  reprobated,  as  it  is  highly  improper;  especially 
as  it  is  every  way  calculated  to  do  mischief,  and  never  to  do  good. 
The  patient  may  be  suffered  to  grasp  the  hand  of  some  one,  as 
the  spasms  approach;  but  if  the  hand  be  contracted,  it  should 
be  suffered  to  remain  so,  until  it  becomes  relaxed. 

All  that  is  useful  in  such  cases  is  to  make  such  opposition  to 
the  patient's  struggles  as  will  prevent  doing  herself  mischief,  by 
striking  herself  too  forcibly ;  or  by  bruising  her  limbs  against 
any  hard  body  that  may  be  in  the  way ;  or  throwing  herself  from 
the  bed.  Again,  a  solid  metal  body  is  thrust  into  the  mouth, 
such  as  the  handle  of  an  iron,  pewter,  or  silver  spoon,  to  prevent 
injury  being  done  to  the  tongue ;  but  all  such  substances  are 
improper,  as  they  frequently  do  much  injury  to  the  teeth.  A 
piece  of  cedar  or  pine,  of  sufficient  length,  and  shaped  like  a 
wedge,  may  be  advantageously  employed. 

After  the  struggling  is  over,  the  patient  will  sometimes  be  very 
sick  at  stomach,  or  even  vomit  violently :  in  such  case  nothing 
is  better  than  a  draught  of  water,  as  warm  as  can  well  be  swal- 
lowed ;  and  this  may  be  repeated  whenever  the  necessity  recurs. 
We  should  not  attempt  to  force  medicines  upon  the  patient  while 
the  stomach  is  thus  disordered. 

In  a  late  conversation  with  my  friend  Dr.  Jackson,  I  learned 
from  him,  that  he  had  found  cold  water  highly  serviceable  in 
hysteria  of  a  certain  character :  he  has  kindly  furnished  me  with 
his  views  upon  this  subject,  and  I  shall,  I  am  sure,  be  rendering 
an  acceptable  service  by  inserting  his  letter  entire. 

"MY  DEAR  SIR, 

"  In  your  note  last  evening,  you  requested  me  to  inform 
you  more  particularly  of  the  employment  of  cold  water  in  hys- 


HYSTERIA.  497 

teria,  which  I  mentioned,  in  conversation  a  few  days  past,  I  had 
found  a  prompt  and  beneficial  remedy,  in  some  cases  of  that  af- 
fection. In  compliance  with  your  desire,  I  present  you  with  the 
following  observations,  and  shall  be  pleased  to  find  you  should 
consider  them  as  meriting  your  attention. 

"  I  was  first  led  to  the  practice  from  observing  some  cases  of 
spasmodic  or  convulsive  movements  of  the  voluntary  muscles,  in 
robust  men,  but  having  a  nervous  temperament,  and  which  were 
excited  by  a  high  degree  of  gastric  irritation.  In  some,  the  acci- 
dents were  attributed  to  drinking  cold  water  whilst  over-heated. 
But  irritants  of  various  kinds,  as  indigestible  food,  alcoholic  li- 
quors, &c.,  had  also  been  taken :  and  the  symptoms  revealed,  when 
attentively  examined,  an  intense  irritation  of  the  stomach.  In 
these  cases,  the  convulsive  agitation  of  the  muscular  system  was 
unattended  with  any  tendency  to  coma  or  stupor ;  the  patients 
were  unable  to  express,  in  language,  their  feelings;  they  were 
conscious  of  every  thing  doing  about  them ;  their  attention  was 
wholly  riveted  on  their  sensations ;  and  when  relieved  they  ac- 
cused the  stomach  and  head  as  the  seats  of  their  sufferings.  The 
convulsive  movements  of  the  voluntary  muscles  were  evidently 
the  result  of  the  gastric  irritation,  forcing  the  will,  and  reflected, 
without  its  concurrence,  into  the  locomotive  apparatus.  All  con- 
curred in  stating,  they  found  it  impossible  to  restrain  the  violence 
of  their  movements.  From  the  view  I  took  of  those  cases,  iced 
water,  or  cold  pump  water  sweetened,  was  given  in  repeated 
small  draughts;  cold  affusions  were  directed  to  the  head,  and 
when  the  circulation  was  excited,  and  the  skin  hot,  blood-letting 
was  practised,  with  cold  ablutions  to  the  general  surface.  The 
relief  from  the  cold  draughts  and  affusions  was  immediate.  The 
convulsive  efforts  became  calm,  and  the  patients  expressed,  in 
extravagant  terms,  the  agreeable  sensations  they  experienced 
from  them,  and  the  rapid  disappearance  of  their  sufferings.  The 
morbid  condition  of  the  system,  in  the  cases  alluded  to,  bears  a 
strong  analogy  to  hysteria,  as  it  is  occasionally  presented  to  us. 

"  Having  subsequently  met  with  some  cases  of  hysteria,  the 
exciting  cause  of  which  was  irritation  of  the  stomach,  produced  by 
improper  food,  or  other  irritants,  I  was  led  to  repeat  the  same 
practice.  The  result  was  equally  prompt  and  favourable.  In  all 
those  cases,  however,  gastric  irritation  was  well  characterized; 
the  epigastrium  was  highly  sensible ;  sentiment  of  interior  heat 
excited,  and  thirst. 

"  The  following  case,  which  came  under  my  care  a  few  days 
past,  illustrates  the  state  of  the  system,  the  morbid  phenomena 
I  allude  to,  and  the  treatment. 

"  Mrs.  W.  is  about  thirty  years  of  age,  of  short  stature,  full 
make,  dark  complexion.  Her  husband  has  been  absent  on  a  voy- 
age several  weeks,  and  no  intelligence  has  been  received  from 
32 


498  HYSTERIA. 

him.  She  lives  retired,  and  uses  very  little  exercise.  She  had 
been  distressed  in  mind  some  days — complained  of  want  of  ap- 
petite and  headache — was  constipated.  She  dined  on  fresh  pork ; 
after  dinner  took  a  cold  bath,  which  was  prolonged  an  unusual 
time;  coming  out  of  the  bath,  she  drank  iced  punch  made  of  old 
Jamaica  rum,  and  early  in  the  evening  took  tea.  Immediately 
after  this  meal,  she  was  seized  with  spasms  of  the  stomach,  vo- 
mited, and  became  much  agitated.  The  spasms  in  the  stomach 
recurred  at  intervals  of  from  five  to  ten  minutes ;  and,  during  each, 
there  was  a  tonic  spasm  of  the  voluntary  muscles,  a  loss  of  con- 
sciousness of  surrounding  objects,  stifled,  suifocated  breathing, 
the  eyes  watery,  and  rolled  upwards.  In  the  intervals,  weeping 
and  great  depression  of  mind.  The  slightest  pressure  on  the 
epigastrium  gave  uneasiness — sensation  of  heat  was  experienced 
in  the  stomach,  and  thirst. 

"At  first  I  gave  her  hydrant  water,  none  colder  being  in  the 
house,  sweetened  with  sugar,  to  drink.  It  did  not  relieve  the 
gastric  distress — ice  was  sent  for,  and  a  large  piece  put  in  the 
pitcher  of  water.  She  drank  small  quantities  every  two  minutes. 
It  was  highly  grateful.  A  single  paroxysm,  only,  recurred  after 
the  iced  water  was  taken.  The  head  was  washed  with  cold  water. 
In  a  case  where  the  heat  of  the  skin  and  head  was  intense,  cloths 
dipped  in  cold  water  and  affusions  were  employed. 

"I  mentioned  my  practice  to  our  friend  Dr.  La  Roche,  who 
put  it  in  operation  in  a  case  of  hysteric  spasms,  that  came  under 
his  care,  after  he  had  tried  the  usual  routine  of  antispasmodics, 
and  which  had  failed  to  give  relief.  The  effect  was  prompt. 

"  The  pathology  of  hysteria  has  been  variously  given  by  dif- 
ferent writers.  The  most  correct  view,  and  which  is  deduced 
from  an  attentive  examination  of  its  phenomena,  refers  to  the 
cerebral  structure  for  its  seat.  The  brain  is  a  collection  of  organs 
of  nearly  similar  composition,  which  preside  over  the  various  in- 
tellectual and  pathetic  faculties,  and  voluntary  motion.  The 
medulla  oblongata  appears  to  be  the  central  organ  of  perception 
and  volition,  and  its  lower  portion  and  the  upper  part  of  the  spinal 
marrow,  govern  the  expressions  and  respiratory  muscles.  Irri- 
tation of  the  upper  portion  of  the  medulla  occasions  spasms,  con- 
vulsions, &c.,  of  the  voluntary  muscles ;  and  of  the  lower  portion, 
irregular  and  spasmodic  contractions  of  the  muscles  of  respira- 
tion, of  the  voice,  and  of  the  face,  as  expressing  the  passions. 
Hence,  the  sense  of  suffocation,  sighing,  screaming,  crying,  laugh- 
ing, weeping,  and  the  various  distortions  of  the  countenance. 

"Individuals  who  experience  frequent  attacks  of  hysteria,  have 
this  portion  of  the  central  structure  in  a  permanent  state  of  irri- 
tation, of  feeble  grade,  and  which  is  increased  by  any  sudden  and 
strong  impression.  An  unexpected  noise,  sight,  or  intelligence, 
becomes  in  them  an  exciting  cause  of  the  hysteric  paroxysm. 
Venereal  irritation,  sufficiently  intense  to  be  transmitted  to  the 


HYSTERIA. 


499 


brain,  is  often  communicated  to  its  central  organ,  and  excites  the 
symptoms  of  hysteria.  The  stomach  and  uterus  are  those  parts 
from  which  this  irritation  is  most  commonly  transmitted,  ,and  is 
effected  through  the  great  sympathetic,  which  anastomoses  with 
the  pneumogastric  or  par  vagum  that  has  its  origin  in  the  me- 
dulla oblongata. 

"  The  varieties  observable  in  hysteria  will  depend,  1st,  on  the 
intensity  and  extent  of  the  cerebral  irritation  ;  2dly,  on  the  local 
visceral  irritation,  by  which  it  is  excited  ;  3dly,  the  organ  that  is 
the  seat  of  the  primary  irritation. 

"  This  pathology  of  hysteria  is  founded  on  the  symptoms,  the 
disturbances  of  functions  it  presents,  and  the  organs  that  accom- 
plish those  functions. 

"  With  respect,  yours  truly, 

"  SAMUEL  JACKSON. 

"  To  Dr.  Wm.  P.  Dewees,  June  29,  1826." 


Preventing  the  Recurrence  of  the  Paroxysms. 

There  are  no  affections  of  the  other  systems  of  the  body  so 
liable  to  recurrence  as  those  which  affect  the  nervous  system. 
This  may  be  owing  either  to  the  difficulty  of  restoring  the  ner- 
vous tone  when  impaired,  though  not  subjected  to  the  continued 
influence  of  the  exciting  causes ;  or  to  the  great  difficulty  of  se- 
curing this  system  sufficiently  long  against  the  operation  of  these 
causes,  that  the  nerves  may  recover  their  ordinary  healthy 
standard. 

The  difficulty  just  suggested  is  particularly  great  in  the  dis- 
ease now  treated  of,  owing  to  the  constant  liability  of  exposure 
to  the  exciting  causes ;  for,  almost  any  severe  intellectual  opera- 
tion, or  any  undue  exercise  of  any  of  the  senses,  may  endanger 
with  relapse  the  ill-restored  nervous  system;  hence  the  diffi- 
culty and  uncertainty  of  a  radical  cure  of  hysteria.  Besides,  the 
best  concerted  plan  that  can  be  devised  will  be  too  certainly  use- 
less, if  co-operation  fail  on  the  part  of  the  patient.  We  have 
already  adverted  to  this  difficulty,  and  it  is  repeated  with  a  view 
to  lessen  an  expectation  of  the  efficacy  of  remedies,  so  commonly 
indulged  in  by  patients  of  this  class,  without  using  their  efforts 
to  secure  their  good  effects. 

To  every  patient  afflicted  with  hysteria,  it  should  be  inculcated 
that  much  may  be  done  by  a  proper  and  persevering  exercise  of 
the  moral  faculties,  and  by  the  judicious  employment  of  their 
physical  powers ;  and  that  on  these,  vastly  more  depends  for  a 
cure,  than  on  the  exhibition  of  medicine;  and,  farther,  that  with- 
out the  healthful  play  of  these  powers,  medicine  alone  cannot 
prevent  the  return  of  evil,  though  it  may  occasionally  alleviate 
a  present  misery.  i 


500  HYSTERIA. 

It  will  be  seen  at  once,  that  part  of  this  plan  must  be  difficult 
of  execution ;  since  the  exciting  causes  are  almost  constantly 
presenting  themselves ;  at  least  it  is  so  with  those  of  the  moral 
kind;  and  these  seem  to  require  more  than  human  resolution, 
or  hmman  foresight,  to  either  interrupt  their  operation,  or  to 
avoid  encountering  them.  Yet  we  know  much  can  be  done, 
when  reason  is  properly  exercised,  or  forbearance  duly  main- 
tained. It  should,  therefore,  always  be  shown  to  patients,  how 
much  depends  upon  themselves  for  a  cure,  by  pointing  out  the 
importance  of  not  yielding  to  sudden  impulses,  nor  indulging  in 
destructive  forebodings.  By  the  one  the  system  is  thrown  into 
violent  and  ungovernable  agitation ;  and  by  the  other  it  is  ren- 
dered so  morbidly  sensitive  as  to  be  operated  on  by  the  slightest 
causes. 

The  physical  exciting  causes  may  be  avoided  with  more  cer- 
tainty, or  their  presence  more  easily  removed,  than  the  moral ; 
yet  to  be  successful  in  preventing  their  operation,  requires  much 
self-denial,  and  entire  conviction  of  the  necessity  of  the  sacrifice. 

It  would  be  difficult  to  point  out  the  causes  of  the  diminution  of 
this  disease  within  the  last  thirty  years,  in  this  city,  though  the 
fact  is  certain,  so  far  at  least  as  we  can  rely  upon  our  own  ob- 
servations. Have  the  temperaments  most  liable  to  this  disease 
been  changed,  by  either  physical  or  moral  causes?  Certain  it; 
is,  that  at  present  we  are  rarely  called  upon  to  attend  in  an  hys- 
terical paroxysm,  whereas  formerly  such  calls  were  frequent.  '  Is 
this  change  to  be  considered  a  real  advantage  to  the  female  ?  It 
might  be  doubtful  if  the  observation  of  Whytt1  be  true;  namelyy 
that  "however  troublesome  and  obstinate  nervous  disorders  may 
often  be,  they  have  some  advantages  attending  them;  for  the 
weak  state  of  the  blood  and  vascular  system,  in  many  of  these 
cases,  renders  such  patients  much  less  subject  to  inflammatory 
diseases  than  those  of  a  stronger  constitution."  Thu»  it  seems, 
that  hysteria,  like  gout,  may  ward  off  severer  blows. 

The  first  general  indication  in  the  cure  of  hysteria  is  to  alter 
that  peculiar  state  of  the  brain  and  nervous  system,  which  gives 
rise  to  the  disease  when  the  exciting  causes  are  applied.  This 
condition  may  consist  in  too  great  a  sensibility  of  the  nervous 
system ;  or  in  such  changes  of  their  sentient  power,  as  to  render 
them  liable  to  be  affected  by  agents  not  ordinarily  offensive,  nor 
inordinately  stimulating,  as  already  explained  above.  Now  could 
this  indication  always  be  fulfilled,  we  could  always  cure  nervous 
or  hysterical  diseases. 

We  have  already  remarked  that  the  nerves  of  almost  every 
part  of  the  body  may,  from  their  sympathy  with  the  brain,  be- 
come affected  with  this  peculiar  condition,  which  gives  rise  to 
"A1"  :  ."V'W-*       '-'7  '',<f  'S?J.i  I";.'].'* 

»  Works,  p.  631. 


HYSTEKIA.  501 

hysteria,  or  at  least  to  nervous  symptoms.  The  intensity  of  these 
symptoms  will  therefore  necessarily  depend  upon  the  force  with 
which  they  may  sympathize  with  /the  brain,  or  upon  their  sensi- 
bility, or  altered  condition  from  health;  hence,  the  same  force 
of  cause  will  produce  very  different  degrees  of  effect  in  different 
individuals.  In  some,  symptoms  may  be  limited  to  palpitation 
of  the  heart,  globus  hystericus,  &c. ;  while  in  others  it  may  be 
followed  by  a  severe  hysterical  paroxysm. 

It  will  follow,  therefore,  caeteris  paribus,  that  the  greater  the 
mobility  of  the  nervous  system,  the  more  difficult  will  it  be  to 
effect  a  cure;  and  that  the  remedies  to  be  employed  must  be  either 
of  great  power,  or  they  must  be  continued  longer.  The  reme- 
dies must  be  addressed  to  the  nervous  system,  through  the  me- 
dium of  the  stomach,  skin  and  mind. 

These  remedies  will  consist  of  tonics,  antispasmodics,  the  cold 
bath,  and  agreeable  impressions  on  the  mind.  The  tonics  will 
comprise  the  various  bitters,  steel,  and  food.  The  bitters  may 
be  the  Peruvian  bark,  sulphate  of  quinine,  gentian,  orange  peel, 
columba  root,  quassia,  &c.:  the  preparations  of  iron,  may  be  the 
carbonate  of  iron,  the  sulphate  of  iron,  the  muriate  of  iron,  the 
aromatic  tincture  of  iron,  &c.  The  antispasmodics  may  be,  the 
castor,  asafcetida,  valerian,  Hoffman's  anodyne  liquor,  ether,  &c. 
The  food,  all  such  as  is  of  easy  assimilation;  as  beef,  mutton, 
p«fltry,  venison,  &c. 

<  in  using  the  various  substances  above  enumerated,  especial 
care  should  be  taken  that  they  are  not  exhibited  in  alcoholic 
menstrua.  Much  mischief  has  been  produced  by  not  attending 
to  this  injunction.  Dr.  Whytt  recommends  even  large  doses  of 
the  bark  and  brandy  to  patients  labouring  under  nervous  or  hys- 
terical affections ;  and  the  weight  of  his  character  has  too  cer- 
tainly perpetuated  the  practice,  both  in  his  own,  and  in  this 
country;  for  he  particularly  extols  the  efficacy  of  the  tincture  of 
bark,  in  his  own  person. 

He  says,  "  I  have  myself  taken  the  above  tincture,  (the  tincture 
of  bark,)  in  the  morning,  for  eight  months  together,  and  with 
remarkable  advantage.  For  three  or  four  years  before,  I  had 
been  troubled  with  much  wind  in  my  stomach,  a  giddiness,  and 
sometimes  a  faintness.  I  observed  in  the  morning,  soon  after 
taking  this  medicine,  a  grateful  sensation  in  my  stomach,  accom- 
panied with  better  spirits  than  I  had  at  any  time  through  the  day, 
or  than  I  ever  found  from  drinking  wine,  even  when  I  used  it 
freely.  I  have  ordered  this  tincture  to  many  patients,  who  have 
taken  it  for  two  or  three  months  successively,  and  after  inter- 
mitting it  for  some  time  have  begun  again.  Most  have  found 
benefit,  and  those  most  who  used  it  longest,"  p.  635. 

Notwithstanding  the  respectability  of  the  authority,  and  the 
high  encomiums  bestowed  upon  this  preparation  of  the  bark,  we 


502  HYSTERIA. 

must  and  do  conscientiously  protest  against  the  spirituous  form 
of  this  or  any  other  of  the  bitters.  We  are  certain  it  is  not  the 
best  under  any  circumstances  in  which  it  is  desirable  or  proper  to 
use  these  drugs ;  and  when  employed  in  the  form  of  tinctures, 
and  especially  to  the  extent  Dr.  Whytt  recommends,  it  very  often 
leads  to  the  habitual  indulgence  of  alcohol,  in  some  shape  or 
other.  We  declare  this  from  repeated  and  ample  observation. 

Indeed  it  may  not  be  amiss,  in  this  place,  to  protest  against 
the  employment  of  any  of  the  tinctures  which  require  large  doses, 
•when  it  can  be  avoided ;  and  especially  the  long  continuance  of 
them,  as  is  too  frequently  done  in  chronic  affections.  The  vehi- 
cle, which  is  brandy,  commonly,  or  even  alcohol  itself,  usually 
contains  but  little  of  the  effective  ingredient;  and  the  patient,  to 
obtain  this  little,  is  obliged  to  swallow  so  much  ardent  spirit,  that 
no  advantage  is  obtained  from  it,  and  is  sure  to  be  injured  by 
the  excessive  use  of  the  vehicle.  To  females,  particularly,  me- 
dicines in  this  form  should  never  be  exhibited;  we  have  known 
but  too  often  serious  evils  to  arise  from  them. 

Modern  chemistry  has  most  happily  discovered  the  active 
principle  of  the  Peruvian  bark,  and  it  is  now  exhibited  with  great 
advantage  in  the  form  of  a  sulphate  or  an  extract.  One  grain 
of  either,  is  supposed,  and  we  think  justly,  to  be  equal  to  at  least 
one  drachm  of  the  best  bark;  therefore,  when  either  of  these 
articles  is  thought  to  be  eligible,  it  can  be  given  in  pills  or  invo- 
lution. The  solution,  it  must  be  remarked,  is  the  more  active 
of  the  two  forms,  if  the  sulphate  be  used.  The  bark  may  bo 
given  in  watery  infusion,  or  decoction,  when  the  sulphate  or  the 
extract  cannot  be  commanded,  but  these  should  be  made  fresh 
every  day,  and  care  taken  to  employ  none  other  than  the  best. 

The  other  bitters  should  always  be  given  in  infusion  or  in  de- 
coction, not  alone  for  the  reasons  just  assigned,  but  because  the 
principle  on  which  their  virtues  depend  is,  perhaps,  less  concen- 
trated than  that  of  the  bark,  and  consequently  the  alcoholic  so- 
lutions of  it  would  be  too  feeble  for  exhibition  with  the  slightest 
chance  of  benefit.  In  using  the  bitters  care  should  be  taken  not 
to  continue  them  too  long  at  a  time. 

Steel,  in  one  shape  or  another,  has  been  the  preferred  tonic 
from  time  immemorial ;  Sydenham  employed  the  filings,  and  Ri- 
verius  the  sulphate  of  this  substance,  while  the  carbonate  is  the 
favourite  form  of  many.  The  one  to  which  we  are  the  most 
wedded  is  the  bitter  tincture  of  iron,  and  is  made  as  follows : — 

R.  Limat.  Ferri,       .         .       V"'v'      gj. 
Rad.  Gentian,  cont.      .         .         .        gij. 
Cort.  Aurant.     ;  .'ii.'v.  .     ,t.-A   i-.-;    gj. 
Sue.  e  pomis  expres.vel  Cider,  .        Biij. 

M.  and  macerate  three  weeks. 

Of  this,  twenty  or  thirty  drops  are  given  in  a  little  sweetened 


HYSTERIA.  503 

water,  morning,  noon  and  evening,  about  fifteen  or  twenty  mi- 
nutes before  eating.  This  medicine  agrees  admirably  with 
stomachs  disposed  to  be  dyspeptic,  and  labouring  under  loss  of 
appetite :  it  may  be  gradually  augmented  if  necessary.  Should 
it  produce  a  sensation  of  weight,  or  as  if  the  stomach  were  con- 
tracting painfully,  the  dose  should  be  diminished  or  desisted 
from.  Steel  may  be  continued  to  almost  any  necessary  period 
without  the  slightest  injury.  It  will  sometimes  disagree  with 
the  stomach,  but  this  is  a  rare  occurrence ;  and  when  it  does,  it 
should  be  instantly  abandoned. 

It  sometimes  purges ;  when  this  happens,  five  drops  of  lauda- 
num should  be  added  to  each  dose :  at  other  times  it  constipates 
the  bowels ;  this  should  be  obviated  by  a  rhubarb  pill  taken  every 
night. 

Antispasmodics  should  only  be  considered  as  palliatives  in  the 
cure  of  hysteria;  but  they  often  become  necessary  during  the 
attempt  to  prevent  the  recurrence  of  the  convulsive  or  other 
paroxysms.  When  the  patient  is  oppressed  by  flatulency,  troubled 
with  globus  hystericus,  or  palpitation  of  the  heart,  either  of  the 
above  named  medicines  may  be  advantageously  employed,  espe- 
cially the  asafoetida,  and  the  Hoffman's  liquor.  The  asafoetida 
is  best  in  watery  solution,  or  in  tincture.  If  the  former  be  em- 
ployed, the  following  formula  may  be  used: — 

•  &•*'•   *    *     '•    '< '  *i **  *f  '  ^      'jf-J^'Y*    '    I    v»!i   '£!*/*     "!    *'    '  i    !~;    ^    v'    i1    '•''''',  <  ^  V      '    *'      '"**»   »V 

R.  Gum  asafcetid.     -  -    Sij. 

Aq.  fervent.          -  -     *iv. 

f.  sol. 

Of  this  a  table-spoonful  may  be  given  pro  re  nata :  if  the  tinc- 
ture be  used,  a  tea-spoonful  in  a  wineglassful  of  water  may  be 
given  and  repeated  as  occasion  may  require.  If  the  Hoffman 
be  preferred,  a  small  tea-spoonful  may  be  given  in  an  ounce  of 
sweetened  water,  taking  care  that  the  sugar  and  water  is  pre- 
pared before  the  liquor  is  poured  out,  and  that  it  be  drunk  im- 
mediately after  it  is  mixed.  It  will  be  necessary  to  avoid  too 
near  approach  to  a  lighted  candle  when  the  Hoffman  is  pre- 
paring. Ether  may  also  be  given  with  advantage,  under  the  same 
restrictions  as  the  Hoffman ;  but  the  latter,  generally  speaking, 
is  the  preferable  medicine.  The  other  remedies  named  as  anti- 
spasmodics  may  be  administered  with  advantage  when  the  symp- 
toms are  not  very  severe,  but  they  are  decidedly  less  effective 
than  those  just  proposed. 

A  very  strict  attention  should  be  paid  to  diet  in  all  nervous  or 
hysterical  affections :  we  are  sorry  to  say,  that  this  part  of  the 
curative  plan  is  too  much  neglected  by  practitioners.  It  is  sup- 
posed that  the  various  articles  of  diet  merit  but  little  considera- 
tion because  the  system  is  labouring  under  no  very  active  or 
acute  disease ;  hence  the  patient  is  generally  directed  to  eat  any 


504  HYSTERIA. 

thing  light.  This  indiscriminate  order  is  almost  constantly 
abused ;  for  the  patient,  not  willing  to  be  restricted,  too  readily 
obeys  the  directions,  though  certain  many  of  the  articles  of  diet 
which  they  are  in  the  habit  of  taking  are  not  friendly  to  the  sto- 
mach, and  they  all  interpret  the  word  "light"  in  favour  of  the 
articles  they  like. 

It  should,  therefore,  be  distinctly  ordered,  that  no  article  which 
is  known  to  disagree  with  the  stomach  or  bowels,  should  be  in- 
dulged in.  Food  may  disagree  in  a  variety  of  ways,  it  may  re- 
main a  long  time  before  it  is  digested ;  it  will  then  occasion  eruc- 
tations, a  sense  of  weight  or  of  pain  about  the  stomach,  a  palpita- 
tion of  the  heart,  headache,  constipation,  diarrhoea,  or  vomiting. 
It  may  turn  acid,  giving  rise  to  flatulency,  burning  in  the  stomach, 
pain,  regurgitations  of  the  contents  of  the  stomach,  oppression, 
distention  of  the  abdomen,  &c.  It  may  simply  produce  costive- 
ness  or  provoke  diarrhoea :  but  in  whatever  manner  it  may  disturb 
the  stomach  or  bowels,  it  should  be  forbidden  the  patient,  and 
some  other  articles  substituted.  As  a  general  rule,  certain  ani- 
mal substances  will  be  found  best,  such  as  beef,  mutton,  lamb ; 
poultry,  as  fowls  and  turkeys ;  fish,  both  scaled  and  shelled,  espe- 
cially the  oyster;  wild  animals,  as  the  deer,  rabbit,  partridge, 
pheasant,  grouse,  &c.  Eggs,  also,  when  soft  boiled,  are  almost 
always  acceptable  to  the  stomach. 

Vegetables  should  not  be  too  freely  indulged  in,  especially  cab- 
bage, cucumbers,  cauliflower,  beans,  onions,  peas,  &c.  The  best 
are  potatoes,  well  mashed,  after  being  boiled  or  roasted ;  rice, 
turnip,  beet,  &c.  But  in  directing  either  of  these,  (for  no  two 
should  be  eaten  at  a  time,)  reference  should  always  be  had  to 
the  experience  of  the  patient. 

The  drinks  of  such  patients  should  be  pure  water,  or  toast  and 
water,  as  a  general  rule ;  it  may  occasionally  be  necessary  to  in- 
dulge them  with  something  a  little  stimulating,  as  weak  brandy 
and  water,  or  good  sherry  or  Madeira  wine ;  but  these  only  at 
dinner.  Tea  and  coffee  should  be  forbidden  when  the  stomach 
is  disposed  to  acidity,  and  milk  or  chocolate  substituted,  where 
these  will  agree.  Good  butter  may  be  taken  with  advantage 
oftentimes,  but  bad  should  be  most  sedulously  avoided.  Hot 
breads  and  cakes  of  every  description  should  be  prohibited,  and 
suppers  most  carefully  refrained  from. 

Costiveness  must  be  carefully  guarded  against  by  either  diet 
or  medicine,  or  both,  if  necessary.  The  substance  best  calculated 
for  this  purpose,  as  an  article  of  diet,  is  the  bread  made  from  the 
unbolted  wheat  flour :  this,  if  regularly  persevered  in,  by  making 
it  the  substitute  for  every  other  kind  of  bread,  will  rarely  fail  to 
answer  this  purpose.  And  as  a  medicine  for  this  end,  the  rhu- 
barb, either  alone,  or  in  combination  with  aloes,  will  rarely  fail. 
The  best  form  of  the  latter  that  we  know  of  is  as  follows : — 


HYSTERIA.  505 


R.  Gum  aloes  sue.    - 
Pulv.  Rhsei. 
Ol.  Caryoph. 
Sapo.  Venet. 
Syr.  Rhaei. 


'    3J- 

-  gut.  iv. 

-  gr.  viij. 

-  q.  s. 

M.  f.  pil.  xxx. 


One  of  these  taken  every  night,  or  every  other  night,  as  the  ne- 
cessity may  be,  will  rarely  fail  to  answer  the  purpose  effectually. 

The  cold  bath  has  justly  been  looked  upon  as  one  of  the  most 
efficient  remedies  of  the  inateria  medica,  in  hysterical  and  ner- 
vous affections ;  its  known  power  in  restoring  muscular  vigour 
after  debilitating  illness,  its  efficacy  in  imparting  tone  to  the  ner- 
vous system,  and  its  acknowledged  control  over  the  vascular 
system,  have  ever  rendered  it  a  popular,  as  well  as  a  very  im- 
portant remedy,  in  cases  of  general  and  of  local  debility. 

But  that  it  may  be  productive  of  its  best  effects,  its  use  must 
be  regulated  by  the  state  of  the  system,  or  the  condition  of  cer- 
tain parts  of  it.  There  are  few  remedies  more  unequivocally 
abused  than  the  cold  bath,  owing  to  the  empirical  manner  in 
which  it  is  prescribed:  on  this  account,  great  caution  must  be 
exercised  when  it  is  about  to  be  used,  that  it  may  not  be  con- 
verted into  an  evil. 

The  primary  effects  of  the  cold  bath  are,  to  produce  a  sen- 
sation, which  is  familiarly  termed  a  shock;  the  skin  becomes 
pale,  and  uneven,  and  hence  the  term  cutis  anserina,  from  its 
resemblance  to  the  skin  of  a  newly  plucked  goose.  The  head 
experiences  a  sense  of  weight ;  the  respiration  for  a  time  is  sus- 
pended, and  then  becomes  quick,  and  sometimes  even  laborious : 
a  severe  oppression  in  the  chest,  as  though  it  were  tightly  corded, 
is  frequently  experienced,  which  sometimes  does  not  pass  off  alto- 
gether, until  the  secondary  stage,  or  the  stage  of  reaction,  takes 
place. 

The  stage  of  reaction  almost  always  takes  place  very  soon 
after  the  fluids  have  been  driven  from  the  surface  to  the  more 
internal  parts;  and  it  is  one  of  the  proofs  of  the  usefulness  of 
this  remedy  and  of  the  propriety  of  continuing  it ;  for  should  no 
reaction  follow,  this  application  must  be  abandoned.  On  this 
account,  the  cold  bath  must  be  used  with  caution,  and  its  effects 
well  ascertained ;  for  its  temperature  must  be  carefully  regulated 
by  the  powers  of  the  system  to  produce  an  after  glow  upon  the 
surface.  It  would  follow  from  hence,  that  this  remedy  may  do- 
mischief,  if  the  temperature  be  neglected,  at  a  time  it  might 
have  been  highly  useful,  had  this  important  point  been  duly  at- 
tended to. 

Hot  and  cold  are  but  relative  terms,  when  applied  to  the  hu- 
man body;  nor  will  the  thermometer  always  settle  the  point, 
where  the  sensation  of  the  one  begins,  or  where  the  other  ends. 


506  HYSTERIA." 

On  this  account  it  is  always  best  to  determine  the  propriety  of 
the  bath,  by  the  sensation  the  application  of  water  may  produce 
upon  the  skin.  This  will  necessarily  vary  in  different  individuals, 
and  in  the  same  individual  under  different  circumstances.  It 
will,  therefore,  always  be  best  to  commence  with  a  temperature 
that  shall  produce  but  a  very  slight  shock,  as  it  can  be  gradually 
reduced,  as  the  capacity  of  the  system  to  produce  reaction  in- 
creases. 

We  are  told  that  the  Buxton  waters,  (England,)  are  at  eighty- 
two  degrees;  yet  they  produce  a  slight  but  a  decided  shock ; 
therefore  it  will  be  well  to  commence  with  water  at  this  tempe- 
rature, and  reduce  it  pro  re  nata ;  or  as  the  sensation  of  cold  may 
be  less  unpleasant,  and  the  reaction  more  decided.  For  if  re- 
action do  not  take  place,  no  advantage  can  be  derived  from  cold 
bathing;  and  this  circumstance  very  properly  forms  one  of  the 
contra-indications  to  the  use  of  this  remedy. 

The  cold  bath  must  not  be  used  when  there  exists  any  visce- 
ral obstruction ;  or  where  there  is  any  pulmonary  affection  or 
local  congestion  of  the  chest. 

It  may  be  used  daily  if  judged  necessary,  when  the  system 
reacts  promptly ;  or  every  other  day,  if  reaction  be  less  decided, 
or  only  twice  a  week,  if  it  be  feeble.  But  we  may  be  always 
justified  in  persevering  in  the  use  of  the  cold  bath,  if  reaction 
takes  place  even  very  moderately;  since  we  almost  always  have 
it  in  our  power  to  regulate  the  force  of  depression  by  the  tem- 
perature of  the  water.  There  are  two  modes  of  employing  this 
remedy ;  first,  by  plunging  into  the  water ;  or  secondly,  by  the 
water  being  showered  over  the  body — the  latter  is  generally  the 
preferable  mode :  it  can  be  done  without  exposure,  and  the  tem- 
perature of  the  water  accurately  ascertained. 

The  best  time  to  use  the  bath,  where  the  constitution  is  pretty 
vigorous,  is  early  in  the  morning;  if  it  be  less  robust,  about  two 
or  three  hours  after  breakfast. 

Some  are  in  the  habit  of  going  to  bed  after  using  the  bath :  we 
cannot  think  this  ever  necessary,  if  the  bath  agree  with  the  pa- 
tient ;  but  should  the  system  react  with  difficulty,  or  too  feebly, 
it  may  be  useful  to  employ  warmth  to  the  surface  in  this  way. 
But  in  cases  of  this  kind,  it  would  be  better  to  abandon  the  re- 
medy, unless  it  be  certain  it  was  employed  at  too  low  a  tem- 
perature, than  to  persevere  in  it,  and  require  artificial  means  to 
promote  reaction.  For  we  must  repeat,  that  the  cold  bath  can  only 
be  useful,  where  it  is  followed  by  a  kindly  glow  upon  the  surface. 

Where  the  system  reacts  slowly  and  feebly,  we  have  seen  ad- 
vantage from  drinking  a  cup  of  warm  chamomile  tea;  indeed, 
almost  any  other  warm  liquid  might  be  employed  upon  such  oc- 
casions, together  with  moderate  exercise,  by  walking  briskly  over 
the  floor.  But  in  all  such  instances,  immediate  attention  should 


HYSTERIA.  507 

be  paid  to  the  temperature  of  the  water ;  it  should  be  increased 
to  at  least  eighty-two  degrees;  and  should  this  produce  so  much 
collapse  as  to  render  reaction  difficult,  or  very  tardy,  we  believe 
it  would  be  best  to  abandon  the  remedy  altogether;  or  at  least, 
until  such  change  may  take  place  in  the  constitution,  as  will 
enable  it  to  bear  water  at  this  temperature.  There  are  consti- 
tutions which  never  profit  by  the  use  of  the  cold  bath;  we  have 
seen  several  such.  It  does  not  depend  upon  the  absence  of  mus- 
cular power,  or  upon  visceral  derangements ;  but  is,  as  in  many 
other  instances  of  peculiarity,  an  idiosyncrasy;  the  system  will 
not  react  but  after  a  long  time,  and  then  feebly  and  transitorily ; 
a  languor  and  indisposition  to  motion  is  experienced;  the  spirits 
remain  depressed  for  many  hours  together;  the  lips  remain  livid; 
and  the  whole  countenance  is  pale,  shrunken,  and  distressed. 
With  such  peculiarity  the  cold  bath  must  not  be  used. 

With  those  whose  systems  react  feebly,  or  those  disposed  to 
take  cold  upon  the  continuance  of  wet  applications  to  any  part 
of  the  body,  the  head  should  always  be  covered  with  a  cap  of 
oiled  silk  during  the  bathing.  Care  should  be  taken  to  dry  the 
body,  after  coming  out  of  the  bath,  as  soon  as  possible;  and  if  the 
body  be  well  rubbed  with  a  coarse  towel  at  this  time,  it  will  con- 
tribute much  to  its  efficacy,  as  it  will  hasten  and  almost  ensure 
the  reaction.  Salt  may  be  dissolved  in  the  water  with  advan- 
tage ;  especially  in  those  whose  systems  are  tardy  in  reacting, 
or  those  who  are  debilitated,  or  have  any  tendency  to  the  lym- 
phatic or  scrofulous  diathesis. 

The  mind  should  if  possible  be  led  from  the  contemplation  of 
the  ills  of  the  body;  it  is  the  very  nature  of  hysterical  and  ner- 
vous complaints,  so  to  disorder  the  judgment,  that  a  true  esti- 
mate cannot  be  formed  of  the  nature,  extent,  or  the  degree  of 
importance,  that  should  attach  to  any  painful  or  distressing  sen- 
sation. The  idea  of  danger  is  almost  constantly  connected  with 
every  feeling  of  the  body :  a  trifling  inconvenience  is  readily 
magnified  into  a  serious  evil;  and  such  patients  will  often  declare 
themselves  to  be  dying  when  little  or  nothing  ails  them. 

Notwithstanding  this  palpable  error  in  the  estimate  of  their 
indisposition,  it  is  not  always  best  to  declare  how  little  we  think 
of  it.  It  is  the  duty  of  the  physician  to  relieve  his  patient  by 
the  best  means  in  his  power;  he  should,  therefore,  employ  them 
in  such  a  manner  as  will  produce  the  best  possible  effect;  and 
whether  they  be  administered  through  the  medium  of  the  mind, 
or  by  the  agency  of  the  stomach,  it  matters  not,  provided  the 
greatest  advantage  be  procured. 

It  should  not,  therefore,  be  considered  disingenuous  in  the 
physician,  if  he  apparently  yield  belief  to  the  statements  of  his 
patients,  or  permit  them  to  indulge,  to  a  certain  extent,  in  their 
delusion :  for,  by  so  doing,  he  oftentimes  obtains  an  advantage 


508  HYSTERIA. 

that  could  not  be  gained  in  any  other  way ;  by  it  he  almost  always 
secures  the  confidence  of  his  patient,  and  sometimes  excites  even 
her  gratitude;  for  it  matters  not,  as  regards  the  feelings  and 
persuasions  of  the  patient,  whether  the  pain  or  inconvenience 
under  which  she  labours  be  purely  imaginary,  or  whether  it  has 
a  real  corporeal  existence. 

The  following  case  in  a  male  will  well  illustrate  our  meaning. 
In  the  year  1803,  Mr.  S.  called  upon  me  for  advice  on  his  case, 
which  he  declared  to  be  an  ill-cured  venereal  affection.  He  was 
a  married  man ;  and  when  under  the  influence  of  wine,  was  led 
to  illicit  enjoyment.  This  was  his  first  and  only  aberration ;  he 
condemned  himself  so  severely  for  this  act,  that  he  constantly 
dwelt  with  intense  solicitude  upon  the  probability  that  he  might 
have  contracted  disease.  He  watched  every  sensation  and  ap- 
pearance of  his  body,  with  the  most  painful  anxiety ;  both  of 
which  were  so  exalted  by  his  imagination,  that  he  fancied  he  had 
the  venereal  disease  in  its  most  decided  form. 

Ashamed  to  make  his  situation  known  to  his  family  physician, 
he  applied  to  a  quack,  who  confirmed  his  fears.  Mercury  was 
administered,  and  a  profuse  salivation  excited ;  but  the  symptoms 
he  so  carefully  cherished  did  not  change.  He  became  dissatis- 
fied, and  sought  another  and  another  quack:  each  in  his  turn 
gave  mercury,  which  so  reduced  him  that  he  was  scarcely  able 
to  walk.  This  discipline  continued  for  about  fourteen  months; 
at  the  end  of  which  time  he  found  his  health  nearly  destroyed, 
and  his  little  property  dissipated,  to  satisfy  the  rapacity  of  these 
merciless  pretenders  to  medicine. 

At  this  period  I  was  consulted :  upon  a  careful  investigation  of 
his  history,  we  were  perfectly  satisfied  that  he  had  never  been  in 
the  slightest  degree  injured,  and  frankly  told  him  so,  and  that  we 
were  satisfied  this  was  the  case.  He  appeared  at  the  moment 
gratified  and  happy  at  our  assurance,  and  went  away  without  a 
prescription.  He,  however,  returned  in  a  few  days,  and  declared 
I  must  be  mistaken ;  for  that  he  was  certainly  diseased.  Finding 
this  notion  to  be  firmly  fixed,  I  thought  it  best  to  meet  him  upon 
his  own  terms.  I  acknowledged  him  to  be  diseased,  but  that  his 
disease  was  completely  under  the  control  of  medicine,  provided 
he  would  strictly  adhere  to  instructions.  He  was  delighted  with 
this  declaration,  and  promised  the  most  faithful  compliance  with 
any  directions  we  might  give. 

I  had  a  box  of  pills  prepared  for  him,  composed  of  bread, 
coloured  with  a  little  rhubarb,  and  scented  with  essential  oil  of 
aniseed.  One  of  these  was  directed  to  be  taken  every  morning, 
noon,  and  night  his  diet  was  prescribed,  &c.  He  returned 
much  delighted  at  the  end  of  a  week,  declaring  that  the  pills  had 
acted  like  a  charm;  that  his  appetite  had  returned;  it  was  even 
voracious ;  that  his  strength  was  improved,  and  that  all  his  vene- 


HYSTEKIA.  509 

redj^ymptoms  were  much  abated.  He  now  begged  to  be  allowed 
to  increase  the  doses  of  the  pills :  this  I  peremptorily  forbade.  He 
persevered  in  the  plan  laid  down  for  him  for  six  weeks,  at  the 
end  of  which  time  he  confessed  himself  to  be  perfectly'well,  and 
every  way  capable  of  attending  to  his  long-neglected  business. 

Success,  in  this  instance,  depended  altogether  upon  yielding 
in  appearance  to  the  perverted  judgment  of  the  patient :  in  the 
same  manner  we  have  often  succeeded  with  hysterical  and  ner- 
vous patients. 

It  must,  however,  be  remarked,  that  there  are  two  distinct 
classes  of  hysterical  and  nervous  patients.  The  first  must  be  in- 
dulged in  their  belief,  that  they  are  seriously  diseased ;  the  other 
must  be  convinced,  that  though  they  experience  many  disagree- 
able feelings,  yet  they  have  not  a  dangerous  tendency.  It  re- 
quires some  caution,  or  investigation,  to  ascertain  to  which  of 
these  classes  any  individual  patient  may  belong;  especially,  if  we 
are  not  previously  acquainted  with  their  opinions  on  the  subject 
of  their  indisposition.  A  little  address,  and  some  inquiry  from 
friends,  will  always  prevent  one  class  being  mistaken  for  the 
other.  In  each,  however,  the  mind  must  be  beguiled  into  the 
belief  that  their  malady  is  susceptible  of  cure. 

Cheerful  company,  agreeable  reading,  and  change  of  scene,1 
should  be  among  the  auxiliary  remedies :  they  should,  however, 
be  so  managed  in  almost  all  instances,  that  the  patient  shall  not 
be  sensible  they  are  prescribed  for  her.  A  little  management 
will  effect  this  desirable  end,  without  the  object  being  revealed. 
No  impatience  should  be  discovered,  while  listening  to  the  ex- 
tended history  of  a  patient's  feelings  and  sufferings;  for  nothing 
is  gained,  in  point  of  time,  in  attempting  to  cut  it  short ;  and  much 
is  lost  if  she  be  led  to  imagine  we  are  regardless  of  what  she  says : 
we  have  ever  found  it  best  to  devote  sufficient  time  to  learn  all 
they  can  say  at  once ;  for  the  subsequent  visits  may  then  be  short, 
since  her  whole  history  has  been  revealed  before.  After  having 
attentively  heard  the  detail  of  symptoms,  the  patient  alway.s 
becomes  anxious  for  the  name  of  her  disease:  our  answer  must 
depend  upon  which  of  the  two  classes  the  patient  belongs.  If  she 
belong  to  the  first,  we  must  beware  how  we  call  her  complaint 
hysterical  or  nervous ;  if  to  the  second,  it  often  becomes  a  source 

1  We  may  effect  this  in  a  variety  of  pleasant  manners;  riding,  walking,  and  sail- 
ing, will  offer  great  resources  of  this  kind;  and  they  should  be  alternated,  or  con- 
tinued, as  circumstances  may  force,  or  utility  suggest.  Neither  of  them  should  be 
persevered  in  so  long  as  to  produce  either  listlessness  or  fatigue:  some  judgment 
will  therefore  be  required  to  render  either  profitable;  but  this  must  be  left,  in  a 
great  measure,  to  the  attending  physician.  Gilchrist  speaks  in  high  terms  of  flail- 
ing: this  mode  of  exercise  is  too  much  neglected  in  this  country,  but  we  trust  this 
will  not  long  remain  a  reproach,  since  our  steamboats  are  becoming  so  numerous, 
and  offer  such  facilities  of  conveyance,  and  such  conveniences  of  regulation,  as 
to  tempt  the  invalid  to  frequent  excursions. 


510  HYSTERIA. 

of  comfort,  that  we  pronounce  it  nervous;  but  explaining  dis- 
tinctly, at  the  same  time,  that  by  nervous  you  wish  to  be  under- 
stood a  real  affection,  but  not  a  dangerous  one ;  for  most  females 
are  well  aware,  and  willing  to  allow,  that  complaints  of  this  kind 
are  not  often  serious  in  their  terminations,  however  permanent 
and  inconvenient  they  may  be  in  their  continuance.  Patients  of 
the  hysterical  and  nervous  class  should  be  kept  from  gossiping 
old  women,  and  never  be  permitted  to  listen  to  the  dismal  ac- 
counts of  the  diseases  of  others. 

For  every  sensation  or  symptom  belonging  to  another,  is  in- 
stantly transferred  to  themselves ;  and  they  will  have  as  many 
diseases  in  turn,  as  they  have  heard  described  to  exist  in  others. 

The  many  disagreeable  sensations  connected  with  hysteria 
make  it  desirable  that  they  should  be  relieved  from  time  to  time 
by  applications  suited  to  such  symptoms ;  and,  happily  for  the 
poor  patient,  we  have  the  most  common,  as  well  as  the  most  dis- 
tressing of  them,  under  pretty  certain  control. 

These  symptoms  are,  palpitation  of  the  heart;  flatulency  ;  glo- 
bus  hystericus ;  and  oppression  about  the  prsecordia.  All  of  these 
sensations  are  very  much  under  the  command  of  the  same  re- 
medies ;  namely  the  antispasmodics  already  mentioned,  such  as 
the  asafoetida,  Hoffman's  anodyne  liquor,  ether,  valerian,  &c. 
But  neither  of  these  should  be  prescribed  at  random :  it  should 
be  carefully  ascertained  that  the  system  will  bear  these  stimuli 
before  they  are  given ;  accordingly,  the  pulse  should  be  examined ; 
and  if  the  artery  does  not  betray  a  plethoric  condition  of  the  vas- 
cular system,  they  may  be  advantageously  given.  But  should 
the  patient  be  plethoric,  the  loss  of  a  few  ounces  of  blood  will 
almost  ensure  the  success  of  the  remedies  just  named;  or  it  may 
even  of  itself  remove  the  whole  of  the  unpleasant  symptoms,  as 
mentioned  above. 


J* 


• 

EXPLANATION  OP  THE  PLATES. 


PLATE  I. 

A  very  distinct  view  of  Carcinoma  Uteri,  and  the  changes 
which  take  place  in  that  viscus  in  consequence  of  this  disease. 

A.  The  carcinomatous  tumour  seated  at  the  posterior  part  of 

the  cervix  of  the  uterus. 

B.  The  os  uteri  much  enlarged,  which  forms  one  of  the  prin- 

cipal characters  of  this  disease,  especially  when  the  sides 
of  the  opening  are  hard  and  resisting,  A  small  portion 
of  the  vagina  is  left  surrounding  the  opening. 

C.  The  cavity  of  the  uterus  near  the  cervix. 

D.  The  cavity  of  the  uterus  near  the  fundus. 

E.  The  fundus  of  the  uterus. 

The  sides  of  the  uterus  are  kept  asunder  by  two  pieces  of 
quill,  placed  transversely  across  the  preparation. 


512  EXPLANATION    OF    THE    PLATES, 


• 


PLATE   II 


A  posterior  view  of  the  same  preparation. 

A.  Shows  a  section  of  the  carcinomatous  tumour,  a  part  of 

which  only  could  be  exposed  in  Plate  I. 

B.  The  fundus  of  the  uterus. 

As  the  size  of  this  drawing  does  not  exceed  the  actual  size  of 
the  preparation,  it  is  obvious  that  all  the  parts  of  the  uterus  have 
undergone  some  degree  of  enlargement. 


A 


EXPLANATION    OF    THE    PLATES.  513 


PLATE   III. 

This  engraving  shows  a  Polypus  of  the  Uterus. 

A.  The  polypus,  in  which  may  be  perceived  a  longitudinal! 

depression,  made  probably  by  the  meatus  urinarius.  It 
is  attached  to  the  fundus  of  the  uterus  by  a  small  neck. 
The  tumour  has  descended  out  of  the  uterus  into  the 
vagina,  which  has  been  slit  open  to  bring  it  into  view. 

B.  The  vagina;  a  few  rugae  remaining  below  the  tumour. 

Higher  up  they  are  obliterated  by  the  distention  of  the1 
parts. 

C.  The  fundus  of  the  uterus,  by  which  the  preparation  i&  sus- 

pended. 

D.  One  of  the  round  ligaments. 

E.  A  part  of  the  left  ovarium. 


514  EXPLANATION    OF    THE    PLATES. 


PLATE    IV. 

•  • 

Views  of  the  three  different  species  of  Polypi,  as  described 
by  Levret.     See  Chapter  on  Polypus. 

Fig.  1. 

A.  The  body  of  the  uterus. 

B.  The  pedicle  of  the  polypus. 
C.C.  The  uterus. 

D.  A  portion  of  the  peritoneum. 

E.  The  bladder. 
F.F.  The  ovaries. 

G.G.  The  Fallopian  tubes. 
H.H.  The  fringed  extremities  of  the  Fallopian  tubes. 

LI.  Portions  of  the  round  ligaments. 
K.K.  Supporters  of  the  preparation. 

Fig,  2. 

A.  The  polypus. 

B.  The  orifice  of  the  uterus. 

C.  The  uterus  with  its  appendages. 

Fig.  3. 

This  figure  represents, 
1st.  The  top  of  the  os  tincse. 
2d.  The  vagina  opened  all  its  length. 

3d.  A  small  polypus  arising  from  a  portion  of  the  internal 
membrane  of  the  uterus. 


Sc 


EXPLANATION    OF    THE    PLATES.  515 


PLATE  V. 

Fleshy  Tubercle  of  the  Uterus. 

A.  The  edge  of  the  tubercle. 

B.  An  incision  made  from  the  fundus  of  the  uterus  to  the  ' 

cervix,  which  shows  that  the  sides  of  the  uterus  are  not 
thickened. 

C.  The  surface  of  the  tubercle,  having  several  irregularities 

upon  it. 

D.  The  os  uteri,  having  undergone  no  change;  indeed,  its 

appearance,  together  with  that  part  of  the  uterus  which 
projects  a  little  into  the  vagina,  may  be  looked  upon  as 
a  specimen  of  a  perfectly  healthy  os  uteri, 

E.  The  vagina  slit  open ;  the  rugae,  and  the  very  irregular 

manner  in  which  they  are  disposed,  are  also  very  correctly 
shown. 


516  EXPLANATION    OF    THE    PLATES. 


PLATE   VI. 

At  the  lower  part  of  the  plate,  there  is  a  rod  for  passing  a 
ligature  round  a  polypus  of  the  uterus.  The  handle  is  made 
hollow  so  as  to  admit  a  part  of  the  rod,  which  is  secured  by  u 
spring  in  the  handle. 

At  the  upper  part  of  the  plate  is  a  wire,  by  means  of  which 
the  ligature  can  be  drawn  through  the  cannula. 

Immediately  below  this  is  the  cannula,  furnished  with  a  shield, 
to  prevent  the  instrument  being  pushed  into  the  vagina  higher 
than  intended  by  the  operator. 

In  the  centre  of  the  plate  is  a  drawing  of  a  hip-bath,  the  di- 
mensions being  given  in  inches.  On  the  left  side  of  the  plate 
is  described  the  best  form  of  a  female  syringe. 


EXPLANATION    OP    THE    PLATES.  517 


PLATE   VII. 

This  plate  shows  a  portion  of  the  hydatids  of  the  uterus. 
The  quantity  voided  by  the  patient  would  have  filled  a  gallon 
measure.  The  preparation  is  suspended  in  the  spirit  by  a  por- 
tion of  organized  coagulating  lymph,  from  which  the  hydatids 
spring,  being  connected  with  it  by  means  of  small  filaments  of 
the  same  substance.  The  cysts  vary  in  size ;  some  of  them  con- 
tain a  fluid,  whilst  others  have  collapsed  in  consequence  of  its 
escape. 


'518  EXPLANATION    OF    THE    PLATES. 


PLATE    VIII. 

An  ovum  to  which  is  attached  a  number  of  hydatids,  and 
which  caused  its  being  cast  off  from  the  uterus.  See  chapter 
on  Hydatids. 

a,a,a,a.  The  size  of  the  ovum,  and  as  large  as  the  original. 
b.  An  incision  into  its  cavity. 

e,c?,<?,c?,£fr.  Hydatids  of  various  sizes,  occupying  the  outside  of 
the  ovum. 

.   :'.!<»  pnr'.-;;i  V'J  f:  i.li'ir  I^iu;^..;   • 
'  .'••  "          jsxla  in  •;••:•.•;•;  J.*t7^  oili1 


Jff^lTE     8. 


it  ii  n, i    77ir  xi\f    mttl   .tltn/n    <>/'  ttir    Orttnt  . 


,  ;$^gpr£Fp|  ( 

IT.  "Ita&'L.  fjtfT -•,-*"'-•  ~jF     «"'     '•  i"*Jtf  •''•?&'•  TflFA3^-'-'**'*'* 

;.^^rj:f.^--^f  >',,  S/ffK*^^%p5p 


EXPLANATION    OF    THE    PLATES.  519 


PLATE    IX. 

In  this  plate  are  two  figures  of  the  cauliflower  excrescence  of 
the  uterus. 

Fig.  1.  Conveys  an  exceedingly  good  idea  of  the  disease,  as 
met  with  in  the  living  body,  the  surface  being  studded 
with  a  number  of  little  granules  heaped  upon  each  other, 
forming  masses  of  an  irregular  shape.  The  lines  drawn 
from  letters  A.  and  B.  terminate  in  different  parts  of  the 
mass.  The  letter  A.  in  a  portion  which  has  a  granulated 
appearance;  the  letter  B.  in  a  small  flocculent  portion, 
which,  having  lost  the  blood  originally  contained  in  it, 
forms  a  fine  light  substance,  which  floats  in  the  spirit. 

Fig.  2.  Shows  the  uterus  of  a  patient  who  died  of  the  cauliflower 
excrescence.  The  preparation  is  suspended  by  the  Fallo- 
pian tubes. 

A.  Points  to  the  loose  flocculent  substance  always  found  after 
death  in  patients  who  have  laboured  under  the  disease. 
During  life,  the  flocculent  substances  being  vascular,  are 
filled  with  blood,  and  a  solid  mass  is  thereby  formed;  but 
these  small  vessels  emptying  themselves,  nothing  remains 
but  their  coats,  which  are  seen  lightly  floating  in  the 
spirit  in  which  the  preparation  is  placed. 

B.  Shows  a  part  of  the  os  uteri,  which  remains  perfectly 
healthy.     Perhaps  this  part  may  be  about  two-fifths  of  its 
whole  circumference. 

C.C.  The  ovaria. 

D.  An  incision  made  through  the  parietes  of  the  uterus, 
which  are  somewhat  thickened. 


520  EXPLANATION    OF    THE    PLATES. 

•»  /  •* 


PLATE   X. 

A  preparation  of  the  corroding  ulcer  of  the  os  uteri. 

A.  Shows  the  ulceration.  A  piece  of  quill  is  placed  so  as  to 
bring  the  whole  surface  into  view.  It  will  be  observed, 
that  the  os  uteri  is  entirely  destroyed  by  the  ulcerative 
process,  but  there  is  not  the  smallest  thickening  of  the 
circumjacent  parts. 

•  B.  Shows  the  vagina  in  a  healthy  state. 
0.  A  small  cyst  in  the  broad  ligaments  containing  pus. 


'*&#•- 


rr.vri:   II1 


EXPLANATION    OF    THE    PLATES.  521 


PLATE   XI. 

Ulcerated  carcinoma  of  the  uterus. 

This  plate,  when  contrasted  with  the  former,  shows  the  uterus 
altogether  much  thickened,  the  cervix  of  the  uterus  especially. 

Two  lines  meet  at  A. ;  these  diverging,  lead  to  the  upper  and 
lower,  or  rather  to  the  anterior  and  posterior  parts  of  the  cervix 
uteri.  All  traces  of  the  os  uteri  are  destroyed. 

The  points  particularly  deserving  of  notice  in  these  plates 
are  ulceration  without  thickening  in  the  corroding  ulcer,  and 
ulceration  with  great  thickening  in  carcinoma. 

B.  The  Fallopian  tube. 


522       EXPLANATION  OF  THE  PLATES 


PLATE   XII. 

Circular  gilt  Pessary. 

Fig.  1.  This  plate  represents  the  middle-sized  pessary. 
From  a,  a.  Two  inches  and  four-tenths. 

b.  A  central  hole  to  permit  any  discharge  to  pass, 

three-tenths  of  an  inch  in  width, 
c,  c.  An  excavation  for  the  neck  of  the  uterus  to  lie  in. 

Fig.  2.  Is  a  central  section  of  the  pessary. 

a,  a.  Represents  the  internal  cavity  of  the  pessary. 

b,  b.  Represents  the  depth  of  the  excavation  of  c,  c,  of 

Fig,  1,  five  and  a  half  tenths  of  an  inch  deep. 

c.  A  section  of  the  central  hole,  6,  of  Fig.  1. 


J'.LuJ.  TK  1* 


tlntiiii/li  ilit1 


INDEX 


A. 

Page. 

ABORTION,  liability  to,  increased  by  plethora  .  . .  .  182 

produced  by  hydatids          .            .            .        -:..  284 
mere  increase  in  the  circulation  not  sufficient  to  pro- 
duce it            ..           .            .                         .  .  313 

Abscess,  in  the  labium      ......  32.V 

milk  ......  451 

Acetate  of  lead,  in  uterine  hemorrhage     ....  322 

Acid,  nitro-muriatic  in  carcinoma  uteri  ....  256 

sulphuric         in        do          do     •    .•  .  .  .  ib. 

pyroligneous  in        do          do  ....  255 

Alum,  in  irregular  menstruation     .  .  .  .  .  147 

Anatomical  peculiarities  of  the  female  ....  18 

Apththous  efflorescence  on  the  female  organs       ...  47 

male  organs  .  .  .  51 

Asafoetida  in  hysteria          ......      492,  &c. 

Astringents  in  uterine  hemorrhage      .....  327 

their  modus  operand!      .  .  ib. 

Leroux:s  objection  to  their  use         .  ib. 

Leake'a  ...  ib. 

their  decided  utility  .  .  ib. 

in  leucorrhcea  ...  72 


B. 

Balsam  copaiva,  in  hemorrhoids          .            .            .            .  .214 

Bleeding,  in  carcinoma  uteri          .  .            :            .  .               245 
decline  of  the  menses          .....         149 

hysteria               .            .  .            .  .               490 

menorrhagia             .            .             .            .            .  .146 

milk  abscess       .            .                    L  .            .  .  456 
pregnancy     .......         185 

puerperal  fever              .  .         •  .            .  .               395 

suppression  of  the  menses               .        "    ^  126 

uterine  hemorrhage       .  .            .        **•  •               321 

Blisters  during  pregnancy        .            .            .'.-.'.  .         190 

in  menorrhagia     .            .                         .  ^        .  146 


524  INDEX. 

Page. 

Blisters  in  puerperal  fever       .            .            .            .            .  .412 

in  hysteria            ......  492 

Blood,  appearance  when  drawn  during  pregnancy     .            .  .192 

Bloody  infiltrations  in  labia  pudendi         ....  35 

causes                         .            .            .            .  .          15 

symptoms,  (see  cases)    ....  37 

treatment        .            .            .            .            .  .37,  &c. 

Borax  in  pruritus    .......  48 


c. 


Calomel  in  puerperal  fever     ......  354 

Camphor  in  painful  menstruation             .             .             .            .  130 

in  carcinoma  uteri                .....  255 

in  hysteria           ......  495 

Cantharides,  tincture  of,  in  leucorrhcea  .  .  .  .72,  &c. 

in  suppression  of  the  menses     .            .  116 

Carbonic  acid  gas  in  carcinoma  uteri  .'  .  .  .251 

Carcinoma  uteri     .......  242 

first  stage,  symptoms  of                     .            .            .  243 

treatment  of    .            .             .            .  244 

by  bleeding      ....  245 

purging        .             .                          .  247 

abstemious  diet            .  249 

cleanliness               .             .             .  250 

>                                           rest       .....  252 

second  stage,  or  where  symptoms  of  ulceration  have 

commenced               ....  253 

treatment  by  narcotics     .            .  254 

antacids             .            .  256 

sweet  cream           .            .  ib. 

diet       ...  249 

Mr.  Clark's  remarks  respecting  the  treatment           .  256 

Cauliflower  excrescence  of  the  uterus      ....  275 

symptoms  of           .....  278 

prognosis            .            .             .            .            .  ib. 

treatment  by  bleeding        ....  280 

diet        ......  ib. 

laxatives     ......  ib. 

astringents        .            .            .            .            .  281 

tonics          ......  ib. 

ligatures             .....  282 

Cellular  system  of  the  female,  peculiarities  of  .  .20 

Cicuta  in  decline  of  the  menses    .            .            .            .            .  145 

carcinoma  uteri             ......  255 

Clarke,  his  classification  of  the  diseases  of  the  uterine  system   .  364 

objections  to            .....  365 

Clitoris,  diseases  of            .            .            .            .            .'•*';  28 

given  rise  to  the  opinion  of  hermaphrodites             .            .  ib. 

scirrhus  of             .            .             •'.;»'•            •  29 

Copaiva  in  hemorrhoids  .  .  .  .  .  .215 

pruritus            ......  49 


INDEX.  525 

Page. 

Cold  bath  in  hysteria               ....          (.4.  .  .        505 

Costiveness  during  pregnancy       ....        .  T.  206 

consequences  of          .            .            »*  '  •        ^06 

treatment    .            .            .           . ,,  .    „  .'.  ib. 

Cream  in  cancinoma  uteri        .            .            .         ' '". .       .f  .,  .        256 

Cutaneous  system  of  the  female    .            .        -.t  .        ( ...    '        .  20 


D. 

Diet  in  carcinoma  uteri  ......        249 

cauliflower  excrescence  of  the  uterus       .            .            .  276 

decline  of  the  menses              .                     .    .            .  .142 

during  pregnancy               .            .             .             .            .  195 

hemorrhoids    .......        213 

leucorrluBa             .            .            .            .            .            .  73 

suppression  of  the  menses       .            .            .            .  .115 

menorrhagia           .            .            .            .            .            .  159 

puerperal  fever            ....           V>  .        423 

milk  abscess           .            .            .            .            .            .  459 

hysteria            .            .            .            .            .    '  .         504 

Diseases  of  the  labia          ......  32 

external  and  internal  organs               ...  25 

DysmenorrhcBa       .            .            .            .            .            .            .  125 

symptoms        .....  ib. 

causes         ......  ib. 

treatment          .            .            .            .            .  .130 

during  the  flow      .            .            .             .            .  129 

the  interval       .             .            .            .  .131 

Dr.  Mackintosh's  view  of  dysmenorrhcea              .            .            .  133 


E. 

Emetics  during  pregnancy       .            .                        .  189 

in  menorrhagia     .            .            .            .            .            .  160 

in  puerperal  fever      ......  444 

in  hysteria  .  .  .  .  .  .  491 

Ergot  in  difficult  menstruation  .  .  .  .  .130 

uterine  hemorrhage  .....  328 

Extirpation  of  the  uterus         ......  233 


F. 

Female,  peculiarities  of  the     ....  17 

peculiar  diseases  of         .....  18 

Fever,  menstrual          ....                         .  100 

milk,  rules  for  preventing              ....  452 


'••*? 

526  INDEX, 

f  Page. 

Fever,  puerperal          .           .           .           .         .•'«•''••  •        347 

definition  of                  .            .            .            .'•••?•.!  ib. 

history        .......        350 

period  of  attack             .            .            .            .            .  373 

predisposing  causes  .....         352 

delivery,  as  a  cause              .            .            .            .  353 

opinions  of  Armstrong,  Hey,  and  Clarke      .  .          ib. 

prophylactics    ......  355 

purgatives,  as     .            .            .            .            .  ib. 

Dr.  Gordon's  opinion  respecting      .            .             .  356 

Key's     .......  ib. 

the  author's               .            .            .            .            .  391 

seat  of        .......         357 

appearances  on  dissection,  in  the  thorax        .            .  ib. 

in  the  abdomen        'V  .          ib. 

is  an  inflammation  of  the  peritoneum             .            .  ib. 

this  inflammation  terminates  in  effusion  .          ib. 
the  belief  that  this  in  effusion  is  not  the  effect  of  active 

inflammation,  erroneous            .             .  .        358 

Dr.  Denman's  opinion  respecting        .            ,            .  371 

symptoms  of                      .            .            .            .  .          ib. 

diagnosis           ......  379 

prognosis                .            .            .            .            .  .381 

contagious  nature  of    .            .            .            .            .  384 

the  author's  opinion  of            .  .          ib. 

Dr.  Hulme's  opinion  of     .            .  ib. 

Dr.  Hull's  ib. 

Mr.  Key's               ...  ib. 

Dr.  Armstrong's            .            .  .         385 

Dr.  Leake's            ...  ib. 

treatment  of          ,            .            .            .            .  .          ib. 

bleeding       .            .            .            ,            .            .  386,  &c. 
stages  of                ......         395 

1st  stage       ......  ib. 

bleeding  in                      .            .            .  ib. 

pulse  as  a  guide  for  bleeding,  &c.    .            .  397 

rules  for  bleeding  in                    .            .  .         403 

2d  stage       ......  407 

purging  in           .            .            .            .  .         409 

.                  emetics          .....  ib. 

blisters  in            .             .             .            .  .412 

fomentations             .            .            .            .  413 

spirit  of  turpentine         .            .            .  .          ib. 

mercurial  frictions    .            .            ,            .  414 

gangrenous  stage        .            .            .            .  .416 

symptoms  of              .             .             .             .  417 

treatment  of                    .            .            ,  .418 

stage  of  effusion,  treatment  of     .            .            .  421 

general  directions  and  rules            .  .        422 

Fluor  albus,  (see  leucorrhoea)        .....  55 

Forceps  in  uterine  hemorrhage  •         .            .            .            .  .333 

Fomentations  in  puerperal  fever                .            .            .            .  413 


f.* 


INDEX.  527 


G.  ...          •£ 

Page. 

Galls  as  an  application  to  hemorrhoids         ....          .  ;' "         .         215 

Guaiacum,  volatile  tincture  of,  in  suppression  of  the  menses       .  118 


H. 


Heartburn  during  pregnancy   ...  .199 

treatment  of             ...  200 

Hemorrhage,  uterine    .            .            .            .            .            .  .311 

connexion  of  the  ovum  with  the  uterus  .               ib 

causes  which  may  destroy  this        .  .         312 
mode  of  action  of  certain  of  the  remote 

causes  of            .  .           ib. 
periods  of  pregnancy  at  which  it  may 

take  place           .  .        316 
1st  period,  the  first  four  and  a  half  months  of 

pregnancy          .  .         318 

treatment  during  this  period      .  .              320 
2d  period,  the  remaining  time  of  utero-gesta- 

tion         .             .  .         326 

danger  in  this  greater  than  in  the  first  .                ib. 

indications  of  cure           .             .             .  .          ib. 

treatment  at  this  period         ...  ib. 
delivery  as  a  mode  of  arresting 

hemorrhage           .  .         328 

vicarious  of  the  menses        .            .  .              100 

Hemorrhoids  during  pregnancy           .            .  .         208 

cause  of    .            .  .              210 

treatment  of    .            .  .211 

after  labour               .  .               ib. 

treatment  of                                     .  ib. 

Hiera  picra  in  the  decline  of  the  menses                           .  145 

Hip  bath  in  carcinoma  uteri     ...  •         257 

Hoffman's  anodyne  liquor  in  carcinoma  uteri       .  255 
Hydatids  of  the  uterus             ... 
causes  of 

case  of  ib. 

diagnosis                 ....  286 

treatment        ....  ib. 

ergot  recommended           .  .              287 
Hymen,  opinions  respecting  its  existence 

imperforate          ...  . 

symptoms  of                   .            .  ib. 

consequences  of         .  il>. 

treatment  of                    .            .            .  .44 

Dr.  Denman's  case  of            .  42 

Dr.  Cleaver's  case  of                               .  45 


Jf-      *£•  .wp 

528  INDEX. 

I 

Page. 

Hysteria  during  pregnancy,  treatment  of       .           ,.            .            .  85 

Hysteria     ......        |KY           .  462 

seat  of           .......  463 

sympathetic  affections  stimulated  by                   .            .  466 

predisposing  causes              .....  468 

importance  of  attending  to  the  state  of  the  vascular 

system,  in  the  treatment  of               ...  484 

case  illustrating  this     .....  485 

period  of  life  at  which  it  most  usually  occurs          .            .  468 

causes  of,  according  to  Whytt    ....  469 

symptoms  of             ......  478 

those  most  obnoxious  to  it                       .            .           '.  479 

exciting  causes  of    .            .            .            .            .            .  470 

wind  and  tough  phlegm  in  the  stomach 

and  bowels      .            .             .  471 

case         ....  ib. 

worms    .            ...            .            .            .  475 

case         ....  ib. 

improper  aliments              ....  476 

scirrhous  and   other  obstructions  in  the 

stomach  and  intestines               .            .  477 

violent  affections  of  the  mind         .            .  ib. 

phenomena  of                  .            .            .            .            .  481 

diagnosis      .......  482 

treatment             ......  ib. 

of  the  paroxysm        .....  489 

bleeding            .....  490 

sedatives  and  antispasmodics        .            .            .  ib. 

pediluvium       .            .            .            .            .  491 

stimulants  to  the  nostrils                .            .  ib. 

enemata            .....  492 

emetics      .            .  ""        .            .            .  ib. 

blisters              .....  493 

purgatives               .....  494 

opium               .....  ib. 

case  illustrating  the  utility  of  .  .495 

camphor            .....  ib. 

local  applications                ....  496 

restraint             .....  ib. 

cold  water              .....  ib. 

bath            .....  504 

to  prevent  the  recurrence  of  the  paroxysm              .            .  598 

tonics     .            .             .            .             .            .  501 

antispasmodics        .  .  .  .  .502 

diet        ......  ib. 

amusements  in                    .            .            .            .  507 

cases  illustrating  the  utility  of       .            .  ib. 
cases  showing  that  hysteria  may  be 
subdued  by  moral  and 

physical  causes        .            .  ib. 

Hysteritis    .......  333 

first  species,  causes  of                      .            .            .            .  ib. 

symptoms     .             .             .             .             .             .  335 

constitutional      .  .  .  .  .  .336 

mixed      .......  340 

treatment,  bleeding  •        '   it          '  '  .341 


INDEX. 

PL    Pa?e- 

Hysteritis,  treatment,  purging              .           '|»  '     •"',  .        '    ,  "'    344 

fomentation             .            .  •        ik  •           '     ib. 

blisters               .            .            .  <        .            .'        345 

sudorifics                   .             •  .^    ••'>.                ib. 

opium                .            .            .  *.     %     .         31o 

emetics                     .  ib. 


I. 


Impregnation  requires  the  united  perfection  of  the  internal  uterine 

surface,  and  at  least  one  of  the  ovaria          .        86 
periods  of  ....  88 

never  takes  place  before  the  inception  of  the 

menses          .  .  .  .  84,  &c. 

never  occurs  after  the  cessation  of  the  menses        85 

Inquietude  and  want  of  sleep  during  pregnancy  '  .  .  20  4 

Inflammation  of  the  peritoneum,  (see  fever,  puerperal)       .  .        347 

Injections  in  leucorrhoaa  .....        72,  &c. 

pruritus  .....  49 

carcinoma  uteri  .  .  .      258,  &c. 

cauliflower  excrescence  of  the  uterus  .        27(5 

Infiltrations,  bloody,  in  labia  pudendi       ....  35 

Iron,  preparations  of,  in  the  decline  of  the  menses,  injurious  .         146 

Irritable  uterus  .  290 


Labia,  abscess  of        ....... 

symptoms  of  ......  ib. 

adhesion  of  .  .  .  .  .  .29 

prophylactic  measures       .  .  .  ib. 

treatment  of.  .  .  .  .  .30 

Dr.  Derunan's  plan  .  .  .  .  31 

erysipelatous  inflammation  of  ....          32 

treatment  of  .  .  ib. 

axlematous  swellings  of  .  .  .  .33 

those  most  liable  to  34 

sequelae  of  .  .  .  ib. 

treatment  of  ...  ib. 

Labour,  its  influence  on  puerperal  lever         .  .  ''.        3.r>.'J 

Lead,  acetate  of,  in  irregular  mens  raation  .  .  1-17 

uterine  hemorrhage        ....         32-2 

menorrhagia  ...  J63 

Lencorrhrpa     ...  C  ....          5.3 

34 


<*. 


530  INDEX. 

Page. 

Leucorrhcca.  causes  which  predispose  to                   «. .  *  .          55 

those  most  obnoxious  to       .            .           T           .  ib. 

circumstances  which  influence  the  discharge     .  .           57 

different  varieties  of               ....  58 

var.  a.  L.  of  direct  irritation      ...  59 

6.  L.  of  indirect  irritation         .            .  ib. 

c.  L.  of  habit          .            .            .  .          ib. 

Gardien's  species  of             ....  ib. 

seat  of     .             .             .             .             .             .  .63 

stages  of        ......  69 

first  stage        ......  70 

symptoms  of      ....  ib. 

treatment  of             .             .            .  .72 

second  stage        .             .            .            .            .  75 

symptoms  of                       .            .  ib. 

treatment  of       ....  ib. 

third  stage     ....            V  .          83 

symptoms  of    .            .            .            .  ib. 

treatment  of            .            .            .  ib. 

nitrate  of  silver  in          ...  77 

Ligatures  in  polypus  of  the  uterus      .            .            .            .  .271 

cauliflower  excrescence  of  the  uterus     .            .  275 

Lime  in  carcinoma  uteri          .            ...            .            .  ,        251 

Lymphatic  system  of  the  female               ....  65 


M. 


Madder  in  suppression  of  the  menses              .            .            .  .116 

Menorrhagia           .            .            .            .            .            .  .              150 

nature  of  the  discharge  in                     .            .  .          ib. 

vessels  by  which  the  discharge  is  furnished  .                ib. 

those  most  obnoxious  to            .            .             .  .154 

symptoms  of            .            .             .            .  .                ib. 

two  varieties  of              .            .            .             .  .155 

first  variety     .....  ib. 

those  most  obnoxious  to                     .  1 57 

treatment  of                                  .  .                ib. 

second  variety      .             .            .            .  .159 

those  most  obnoxious  to              .  .               160 

symptoms  of  ib. 

treatment  of                     .            .  .                ib. 

a  third  variety,  supposed  to  exist  by  Gardien  .         161 

Menses,  period  at  which  they  make  their  appearance  .        90,  &c. 

causes  which  influence  the               .             .            .  .92 

premature  appearance  of  ....          85,  89 

derangement  of  the              .            .            .             .  .101 

the  too  tardy  appearance  of  the              ...  ib. 

four  conditions  of  the  system  in  which  this  occurs  .        203 

cond.  a.  where  there  is  little  or  no  development  of  the 

genital  organs          .             .             .  .           ib. 

characters  of  this  condition                .  T*              ib. 

management  of  this  condition     .            .  .          ib. 


INDEX.  531 


Menses,  cond.  b.   where  the   development  is  taking  place  very 

slowly  .....         104 

character  of  this  condition       .  .        * .+,  ll  ib. 

management  of  this  condition      .*         .  .          ib. 

cond.  c.  where    this    development    is    interrupted    by  a 

chronic  affection  of  some  other  part  .         106 

character  of  this  condition       ...  ib. 

management  of  this  condition      .  .  .          ib. 

cond.  d.  where  the  most  perfect  development  has  taken 

place  .....         107 

character  of  this  condition       ...  ib. 

management  of  this  condition       .  .  .          ib. 

cases  of    .  .  .  .  .  ib. 

quantity  usually  expended          ....  92 

causes  which  influence  the     ...  ib. 

sparing  quantity  of  the    .  .  .  .  .121 

treatment  of    .....  ib. 

immoderate  flow  of  the  .  .  .  .122 

suppression  of  the      .  .  .  .  .  1 10 

cold,  the  most  common  cause  of  .         Ill 

symptoms         .  .  .  .  112 

treatment  of  .  .  .  .113 

treatment  of  sudden      ...  ib 

cases  of  .  .  .  .116 

every  deviation  from  regularity  does  not  require  medical 

interference  .  .  .  113 

decline  of  the       .  .  .  .  .  .138 

symptoms  attending  the     .  .  .  139 

treatment          .  .  .  .  .142 

derangements  about  the  period  of  the         .  141 

concomitant  affection  .  .  .          ib. 

may  return  after  they  have  ceased    ...  87 

Menstrual  action  essential  to  impregnation  .  .  .83 

discharge,  a  genuine  secretion  .  .  . '  95 

furnished  by  the  lining  of  the  uterus    .  .          ib. 

in  what  it  differs  from  pure  blood  .  ib. 

derangement  of  ....         102 

quality  of    .  .  .  .  97,  &c 

hemorrhages  vicarious,  of  the  ...          99 
fever,  does  not  exist     .....  100 

Menstruation,  history  of          ......          80 

peculiar  to  the  human  female         .  .  .  ib. 

an  original  function      .  .  .  .  .81 

Roussel's  opinion         ...  ib. 

Galen's       .....  ib. 

not  a  fortuitous  discharge  ...  83 

symptoms  of    .  .  .  .  .  .91 

period  employed  by  ....  92 

precocious         ......          85 

painful         .  .  .  .  .  .  125 

causes  of  .  .  .  ib. 

two  states  of  .  .  .  .  126 

membrane  discharged  during    .  .  ib. 

treatment  of  ....  161 

as  a  sign  of  fecundity  ....          85 

Menorrhagia          .  .  .  .  .  .  .  150 

two  varieties       ....  .155 


532  INDEX. 

Page. 

Menorrhagia,  exciting  causes            Vi'        •            •*        *•  ••'  •         *^ 

treatment             I   ,            .            .            .            ,  157 

Mercurial  ointment,  in  erysipelatous  inflammation  of  the  labia  .           32 

in  puerperal  fever     .             .         .  •„            .  414 

Milk  abscess                .             .            .          v            .        ^; .!..  .         451 

causes  of,  and  prevention                               «*  453 

symptoms  of        .        ;  r-.  <     «   .•*"       .  ~zA        .  .          ib. 

progress  of    .            .          ;  Jf         .          rfc            .  454 

treatment  of                     .            .            .            .  .455 

Milk  abscesses,  local  applications,  vinegar           .            .            .  456 

leeching            .....  ib. 

regimen      .....  459 

purging             .                         .             .  .          ib. 

puncturing             .            .            .            .            .  ib. 

caustic              ......  460 

seton,  operation  of  Dr.  Phy sick     ...  ib. 

after  treatment             .            .            .            i&  ,        461 

Mother  and  fetus,  mode  of  communication  between       .             .  193 

Schreger's  opinion  respecting         .  .          ib. 

Muscular  system  of  the  female     .            .            .            .            .  19 


N. 


Nervous  system  of  the  female  .  .  .  .  .19 

Nitrate  of  silver,  its  use  in  leucorrhcea  ....  78 

Nymphse,  enlargement  of  .  .  .  .  .26 

inflammation  of             .  "  .            .            .            .                ib. 

extirpation  of  ....          27 


0. 


Osseous  system  of  the  female  .....  18 

Ovaria,  when  incomplete,  cannot  furnish  perfect  ova  .  .  87 

may  regain  their  power         ..... 

diseases  of  the       ......  237 

classification  of  .  238 


P. 


Pain  in  the  right  side  during  pregnancy        ....        202 

cause  of  .»*         .  203 

treatment  of  .  .          ib. 


INDEX.  533 

Page.   ^ 
Palpitation  of  the  heart  .          '<•  .  .  .  .216 

causes  of                .             .                     «•>  . .  ib. 

treatment  of    .            .            .            *       >   |p  ib. 

Pessary,  description  of  the  one  used  by  author                .            .  223 

directions  for  placing  it         .            .            .            .            .  224 

proper  size  of     ......  ib. 

remedies  to  be  administered,  before  applying  it      .            .  226 

period  it  must  be  worn                ....  ib. 

Placenta,  circumstances  in  uterine  hemorrhage,  in  which  it  ought  to 

be  removed        .            .            .  324 

directions  for  removing  it     .            .            .            .  *         .  ib. 

Polypus  of  the  uterus        .            .            .            .            .        *  ,  260 

definition  of                  .            .            .  ib. 

causes  of     .            .             .            Jf            .  ib. 

three  species  made  by  Levret               .            .  262 

1st  species  having  its  origin  from  the  fundus  ib. 

symptoms              .            .            .            .  ib. 

mechanism  of  expulsion           .            .  263 

signs  by  which  it  may  be  known               .  262 

2d  sp.  having  its  origin  from  the  neck    .  265 
3d  sp.  having  its  attachment  to  the  orifice  of 

the  uterus            .            .           V*  ib. 
characters  by  which  it  may  be 

known          .            .  ib. 

treatment  of                  .            .            .  ib. 

cases  of                    .            .            .            .  266 

application  of  ligature  .  .  .271 

Pregnancy,  general  condition  of  the  system  during         .          •  '.  180 

febrile         do.     .            .            .            .            .   .     *'„  191 

signs  generally  accompanying  it                    .            .  161 

1.  suppression  of  the  menses         .            .            .  162 

2.  nausea  and  vomiting            .             .             .  167 

3.  enlargement  of  mammae           .            .            .  168 

4.  areolse          .....  ib. 

5.  formation  of  milk          .  .  .  .169 

6.  enlargement  of  the  abdomen           .            .  170 

7.  increased  size  of  the  uterus      .            .            .  171 

8.  pouting  of  the  navel             .            .            .  172 

9.  frothy  spittle      ...                         .  ib. 

10.  salivation     .             .            .            .             .  173 

11.  quickening        .....  174 
itself  not  a  morbid  state         .            .            .            .  180 
peculiarities  during          .....  182 
propriety  of  bleeding  during              .             .            .  186 

purging    do.     .....  187 

vomiting  do.            .            .            .             .  189 

blistering  do.  .  .  .  .190 

liability  to  abortion  do.           .            .             .            .  182 

diseases  of  .  .  .  .  .191 

vomiting     .             .             .             .             .             .  195 

heartburn        v.  .  .  .  .  .199 

salivation                  .....  200 

pain  in  the  right  side                 ....  202 

inquietude  and  want  of  sleep         .            .            .  204 

costiveness       ......  205 

hemorrhoids           .....  208 

pruritus             ......  46 


534  INDEX. 


Page. 

Phlegmasia  dolens       ....            :  «••      ._...""    !*.£••  424 

phlebitis  different  from           •   .            .            .  438 

cases            .            <A  •'•'•'•'•            •             •  439 

treatment          p£;»        •    »•  •       -.-  '         .  446 

blood-letting,  &c.       :,  •       ....;.    ^v            .  447 

purging     .            .            .           '**r-         .  ib. 

topical  applications                ..;  ^        „<           .  ib. 

opium                .            .        |^.::        .  448 

external  applications              .            .          ~, .  449 

blisters              ....  ib. 

bandaging               .            .            .            . '  450 

Prolapsus  uteri      ,            .            .            .            .            .            .  218 

causes  of         .            .            ;.w         .            .  ib. 

Gardien's  three  degrees  of             .            .             .  219 

symptoms      .        *»/'           .            .  ib. 

diagnosis,  difficult            .            .  221 

remedy          .            .          '"I            .  ibj 

cases  of                ...  226 

Pruritus             ........  46 

causes  of             ......  ib. 

treatment  of               ......  49 

a  distinct  affection  from  furor  uterinus                .             .  50 

may  be  communicated  to  the  male              .            .            .  51 

variety  of,  described  by  Chambon          .            .            .  52 

in  children                 .            .....  53 

treatment  of                ....  ib. 

Puberty,  female  diseases  at     .  .  .  .  .  .18 

Puerperal  fever,  (see  fever,)                  •   .            .             .            .  347 

Pyroligneous  acid  in  carcinoma  uteri  .  .  .  .251 


Q. 

Quickening,  what        .  .  .  .  -.-  .  .        174 


R. 

Rest  in  carcinoma  uteri           .            .            .           ..."  *        .  .         252 

Retention  of  urine,  from  blisters  ....  190 

Rhatany  in  irregular  menstruation      .             .            .            .  .146 


s. 

Salivation  during  pregnancy  f  200 

symptoms  attending  it  .  .  ib. 

treatment  of  .  ••'*-.•,.  •  202 

Sanguiferous  system  of  the  female            .            .            v           •  J9 


INDEX.  535 

Page. 

Secale  cornutum,  in  hydatids  .  .  .  '.  *  286 

Sleep,  inquietude  and  want  of,  during  pregnancy  f*,  .  204 

Dr.  Denman's  theory  of  .            .          ib. 

treatment  of  .  ''  .  *.  205 

Sulphur,  its  use  in  hemorrhoids  .  .  .  .  .214 

Dr.  Leake's  opinion  of    .  .                ib. 

Dr.  Good's  ib. 

Sympathies  called  forth  in  pregnancy  .  .  .  .  181 

Sympathy  between  the  uterus  and  rectum  .  .  .  .189 


T. 

Tampon,  directions  for  forming  and  applying  it                                  .  322 

objections  which  have  been  urged  against  its  use         .  327 

modus  operandi  of  the         .....  ib. 

Temperament,  predominant  one  in  females         .            .            .  21 

Tonics  during  pregnancy        ......  185 

in  derangement  of  the  menses  about  the  period  of  their  decline  145 

Tubes,  diseases  of             ......  236 

Tumours  and  excrescences  of  the  external  parts        ...  26 

Turpentine,  spirit  of,  in  carcinoma  uteri                .            .            .  255 

in  puerperal  fever          .  .  .  .413 


IT. 

Umbilical  vein,  uses  of  .  .  .  .  .193 

Urine,  retention  of,  from  blisters  ....  190 

Uterus,  displacement  of,         .  .  .  .  .  .218 

hemorrhage  from  .  .  .  .  .  311 

connexion  of  ovum  with        .....          ib. 

causes  which  may  destroy  it  .  .  .  312 

displacements  of,  action  of  remote  causes     .  .  ib. 

periods  at  which  it  may  take  place       .  .  .  316 

first  period,  a.  .  .  .  .  .318 

second  period,  6.  .....  326 

delivery  in  hemorrhage      .....         328 

lined  by  a  mucous  membrane      ....  96 

lining  of,  supposed  by  some  to  be  deciduous  .  .          ib. 

prolapsus  of,  (see  prolapsus)        .  .  .  .  218 

inflammation  of,  (see  hysteritis)        .  .  .         333 

chronic  inversion  of  .  .  .  231 

irritable  *  .....         290 

diseases  of  ......  236 

carcinoma  of  ......         242 

particular  diseases  of  .  .  .  .  240 

Uterine  system,  influence  of  .  .  .  .  .21 

opinion  of  Sydenham,  Cullcn,  Good;  &c..  respecting          ib. 
the  author's  opinion  ....          22 

Mr.  Fogo's          .  .  .  .    '  24 


• 

>>•  * 

536  INDEX. 

Page. 

Uterine  contraction,  how  far  we  can  control  it       '  •  .    •     •    J»;i        .         313 

Mr.  Burns' opinion       .         :    »         «•«''  .  314 

the  author's  .  .  .  .  ib. 

cases  x)f;  in  which  we  should  not  interfere  .  .  315 

in  all  other  cases,  should  try  to  preserve  the  ovum         ib. 


V. 

Vagina,  natural  diseases  of     .             .            .            .            .  .54 

abbreviation,  or  contraction  of      ....  ib. 

treatment        .            .  .          ib. 

,     accidental  diseases  of        .....  55 

cohesion  of  the  sides  of        >V  •       ;.            .            .  ib. 

cicatrices  of                        .                                      ;             .  ib. 

treatment  of             .             .            .  ib. 

Vein,  umbilical,  uses  of    .            .             .            .             .             .  193 

Vinegar  in  milk  abscesses      .            .                         .            .  .         456 

Vomiting  during  pregnancy,  (see  pregnancy)       .            .*           .  195 


w. 

Warts  on  the  vulva,  treatment  of  .  .  .  .26 


THE  END. 


"     *    ""V 


3  1970  00488  9561 

^r  4',  RK-iU'-AL  LIBRARY  FACILITY 


A    001  285131    7 


